Self-sealing device and method for delivery of a therapeutic agent through a pneumostoma

ABSTRACT

A pneumostoma management system includes a pneumostoma management device for maintaining the patency of a pneumostoma and a drug delivery device for pneumostoma care. The drug delivery device may be used to introduce therapeutic agents into the pneumostoma for direct treatment of the pneumostoma, treatment of the lung by way of collateral ventilation, and/or treatment of non-lung tissues by diffusion into the bloodstream. The drug delivery device includes a therapeutic agent dispenser for supplying a therapeutic agent and a propellant at positive pressure, an outlet and a connector for correctly positioning the outlet relative to a pneumostoma management device. The drug delivery device includes a self-centering and self-sealing connector for engaging the pneumostoma management device.

CLAIM TO PRIORITY

This application claims priority to all of the following applicationsincluding: U.S. Provisional Application No. 61/029,830, filed Feb. 19,2008, entitled “ENHANCED PNEUMOSTOMA MANAGEMENT DEVICE AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06013US0);

U.S. Provisional Application No. 61/032,877, filed Feb. 29, 2008,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FOR TREATMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06001US0);

U.S. Provisional Application No. 61/038,371, filed Mar. 20, 2008,entitled “SURGICAL PROCEDURE AND INSTRUMENT TO CREATE A PNEUMOSTOMA ANDTREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06000US0);

U.S. Provisional Application No. 61/082,892, filed Jul. 23, 2008,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM HAVING A COSMETIC AND/ORPROTECTIVE COVER” (Attorney Docket No. LUNG1-06008US0);

U.S. Provisional Application No. 61/083,573, filed Jul. 25, 2008,entitled “DEVICES AND METHODS FOR DELIVERY OF A THERAPEUTIC AGENTTHROUGH A PNEUMOSTOMA” (Attorney Docket No. LUNG1-06003US0);

U.S. Provisional Application No. 61/084,559, filed Jul. 29, 2008,entitled “ASPIRATOR FOR PNEUMOSTOMA MANAGEMENT” (Attorney Docket No.LUNG1-06011US0);

U.S. Provisional Application No. 61/088,118, filed Aug. 12, 2008,entitled “FLEXIBLE PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06004US0);

U.S. Provisional Application No. 61/143,298, filed Jan. 8, 2009,entitled “METHODS AND APPARATUS FOR THE CRYOTHERAPY CREATION ORRE-CREATION OF PNEUMOSTOMY” (Attorney Docket No. LUNG1-06006US0); and

U.S. Provisional Application No. 61/151,581, filed Feb. 11, 2009,entitled “SURGICAL INSTRUMENTS AND PROCEDURES TO CREATE A PNEUMOSTOMAAND TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06002US0).

All of the afore-mentioned applications are incorporated herein byreference in their entireties.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is related to all of the above provisional applicationsand all the patent applications that claim priority thereto including:

This application is related to all of the following applicationsincluding U.S. patent application Ser. No. 12/______, filed Feb. 18,2009, entitled “ENHANCED PNEUMOSTOMA MANAGEMENT DEVICE AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06013US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FOR TREATMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06001US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PNEUMOSTOMA MANAGEMENT METHOD FOR TREATMENT OF CHRONICOBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No. LUNG1-06001US2);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “TWO-PHASE SURGICAL PROCEDURE FOR CREATING A PNEUMOSTOMA TOTREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06000US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ACCELERATED TWO-PHASE SURGICAL PROCEDURE FOR CREATING APNEUMOSTOMA TO TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (AttorneyDocket No. LUNG1-06000US2);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “SINGLE-PHASE SURGICAL PROCEDURE FOR CREATING A PNEUMOSTOMA TOTREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06000US3);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PERCUTANEOUS SINGLE-PHASE SURGICAL PROCEDURE FOR CREATING APNEUMSOTOMA TO TREAT CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (AttorneyDocket No. LUNG1-06000US4);

U.S. patent application Ser. No. 12/______, filed Feb. 13, 2009,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM HAVING A COSTMETIC AND/ORPROTECTIVE COVER” (Attorney Docket No. LUNG1-06008US1)

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ASPIRATOR FOR PNEUMOSTOMA MANAGEMENT” (Attorney Docket No.LUNG1-06011US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ASPIRATOR AND METHOD FOR PNEUMOSTOMA MANAGEMENT” (AttorneyDocket No. LUNG1-06011US2);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “FLEXIBLE PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06004US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “METHODS AND DEVICES FOR FOLLOW-UP CARE AND TREATMENT OF APNEUMOSTOMA” (Attorney Docket No. LUNG1-06006US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “SURGICAL INSTRUMENTS FOR CREATING A PNEUMOSTOMA AND TREATINGCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06002US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “ONE-PIECE PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06017US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “PNEUMOSTOMA MANAGEMENT SYSTEM WITH SECRETION MANAGEMENTFEATURES FOR TREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE”(Attorney Docket No. LUNG1-06019US1);

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “MULTI-LAYER PNEUMOSTOMA MANAGEMENT SYSTEM AND METHODS FORTREATMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06022US1); and

U.S. patent application Ser. No. 12/______, filed Feb. 18, 2009,entitled “VARIABLE LENGTH PNEUMOSTOMA MANAGEMENT SYSTEM FOR TREATMENT OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE” (Attorney Docket No.LUNG1-06023US1).

All of the afore-mentioned applications are incorporated herein byreference in their entireties. This patent application also incorporatesby reference in their entireties all patents, applications, and articlesdiscussed and/or cited herein.

BACKGROUND OF THE INVENTION

In the United States alone, approximately 14 million people suffer fromsome form of Chronic Obstructive Pulmonary Disease (COPD). However anadditional ten million adults have evidence of impaired lung functionindicating that COPD may be significantly underdiagnosed. The cost ofCOPD to the nation in 2002 was estimated to be $32.1 billion. Medicareexpenses for COPD beneficiaries were nearly 2.5 times that of theexpenditures for all other patients. Direct medical services accountedfor $18.0 billion, and indirect cost of morbidity and prematuremortality was $14.1 billion. COPD is the fourth leading cause of deathin the U.S. and is projected to be the third leading cause of death forboth males and females by the year 2020.

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease ofthe airways that is characterized by a gradual loss of lung function. Inthe United States, the term COPD includes chronic bronchitis, chronicobstructive bronchitis, and emphysema, or combinations of theseconditions. In emphysema the alveoli walls of the lung tissue areprogressively weakened and lose their elastic recoil. The breakdown oflung tissue causes progressive loss of elastic recoil and the loss ofradial support of the airways which traps residual air in the lung. Thisincreases the work of exhaling and leads to hyperinflation of the lung.When the lungs become hyperinflated, forced expiration cannot reduce theresidual volume of the lungs because the force exerted to empty thelungs collapses the small airways and blocks air from being exhaled. Asthe disease progresses, the inspiratory capacity and air exchangesurface area of the lungs is reduced until air exchange becomesseriously impaired and the individual can only take short shallowlabored breaths (dyspnea).

The symptoms of COPD can range from the chronic cough and sputumproduction of chronic bronchitis to the severe disabling shortness ofbreath of emphysema. In some individuals, chronic cough and sputumproduction are the first signs that they are at risk for developing theairflow obstruction and shortness of breath characteristic of COPD. Withcontinued exposure to cigarettes or noxious particles, the diseaseprogresses and individuals with COPD increasingly lose their ability tobreathe. Acute infections or certain weather conditions may temporarilyworsen symptoms (exacerbations), occasionally where hospitalization maybe required. In others, shortness of breath may be the first indicationof the disease. The diagnosis of COPD is confirmed by the presence ofairway obstruction on testing with spirometry. Ultimately, severeemphysema may lead to severe dyspnea, severe limitation of dailyactivities, illness and death.

There is no cure for COPD or pulmonary emphysema, only varioustreatments for ameliorating the symptoms. The goal of current treatmentsis to help people live with the disease more comfortably and to preventthe progression of the disease. The current options include: self-care(e.g., quitting smoking), therapeutic agents (such as bronchodilatorswhich do not address emphysema physiology), long-term oxygen therapy,and surgery (lung transplantation and lung volume reduction surgery).Lung Volume Reduction Surgery (LVRS) is an invasive procedure primarilyfor patients who have a localized (heterogeneous) version of emphysema;in which, the most diseased area of the lung is surgically removed toallow the remaining tissue to work more efficiently. Patients withdiffuse emphysema cannot be treated with LVRS, and typically only havelung transplantation as an end-stage option. However, many patients arenot candidates for such a taxing procedure.

A number of less-invasive surgical methods have been proposed forameliorating the symptoms of COPD. In one approach new windows areopened inside the lung to allow air to more easily escape from thediseased tissue into the natural airways. These windows are kept openwith permanently implanted stents. Other approaches attempt to seal offand shrink portions of the hyperinflated lung using chemical treatmentsand/or implantable plugs. However, these proposals remain significantlyinvasive and are still in clinical trails. None of the surgicalapproaches to treatment of COPD has been widely adopted. Therefore, alarge unmet need remains for a medical procedure that can sufficientlyalleviate the debilitating effects of COPD and emphysema and is acceptedby physicians and patients.

Additionally, respiratory diseases like asthma and COPD are typicallytreated with inhaled therapeutic agents in order to relievebronchoconstriction and inflammation in the lung tissue. There areseveral advantages to administering these therapeutic agents via theinhaled route compared to oral therapy including for example, a fasteronset of action, lower therapeutic agent doses and a better efficacyto-safety ratio. therapeutic agent delivery by inhalation is alsopainless and is more convenient than injectable therapeutic agents andthus patient acceptance and compliance is more likely. However, deliveryof therapeutic agents into lung tissue is difficult in asthma and COPDtreatment because some patients cannot take the deep breathe necessaryto inhale an therapeutic agent aerosol or therapeutic agent powder deepinto the lung. Also many of the inhaler device are difficult to operate.Significant and variable amounts of the therapeutic agent are filteredand/or absorbed in the upper respiratory tract. Thus inhaled therapeuticagent delivery is difficult of impossible in the very patients thatwould benefit most.

SUMMARY OF THE INVENTION

In view of the disadvantages of the state of the art, Applicants havedeveloped a method for treating COPD in which an artificial passagewayis made through the chest wall into the lung. An anastomosis is formedbetween the artificial passageway and the lung by creating a pleurodesisbetween the visceral and parietal membranes surrounding the passagewayas it enters the lung. The pleurodesis prevents air from entering thepleural cavity and causing a pneumothorax (deflation of the lung due toair pressure in the pleural cavity). The pleurodesis is stabilized by afibrotic healing response between the membranes. The artificialpassageway through the chest wall also becomes epithelialized. Theresult is a stable artificial aperture through the chest wall whichcommunicates with the parenchymal tissue of the lung.

The artificial aperture into the lung through the chest is referred toherein as a pneumostoma. A pneumostoma provides an extra pathway thatallows air to exit the lung while bypassing the natural airways whichhave been impaired by COPD and emphysema. By providing this ventilationbypass, the pneumostoma allows the stale air trapped in the lung toescape from the lung thereby shrinking the lung (reducinghyperinflation). By shrinking the lung, the ventilation bypass reducesbreathing effort (reducing dyspnea), allows more fresh air to be drawnin through the natural airways and increases the effectiveness of all ofthe tissues of the lung for gas exchange. Increasing the effectivenessof gas exchange allows for increased absorption of oxygen into thebloodstream and also increased removal of carbon dioxide. Reducing theamount of carbon dioxide retained in the lung reduces hypercapnia whichalso reduces dyspnea. The pneumostoma thereby achieves the advantages oflung volume reduction surgery without surgically removing or sealing offa portion of the lung.

In accordance with an embodiment, the present invention provides apneumostoma management system including a pneumostoma management deviceand a drug delivery device which interacts with one or more componentsof the pneumostoma management device to safely and effectively applytherapeutic agent delivery to a pneumostoma. The drug delivery devicedelivers a therapeutic agent aerosol or therapeutic agent powder deepinto the parenchymal tissue of the lung. Therapeutic agents are not lostto filtration in the respiratory tract and thus the delivery is lessvariable. As a consequence, dosage is more controlled and can be reducedcompared to dosage required by other delivery methods such as oral orinhaled.

In accordance with a general embodiment, the present invention providesa drug delivery device and method to safely and effectively applytherapeutic agent delivery to a pneumostoma.

In accordance with one embodiment, the present invention provides apneumostoma management system which includes a partially-implantablepneumostoma vent, a chest mount and a drug delivery device. The drugdelivery device attaches to the chest mount to safely and effectivelyapply therapeutic agent delivery to a pneumostoma.

In accordance with one embodiment, the present invention provides apneumostoma management system which includes a partially-implantablepneumostoma vent, a chest mount and drug delivery device. The chestmount is secured to the skin of the patient. The drug delivery deviceattaches to the chest mount in the absence of the pneumostoma vent.

In accordance with one embodiment, the present invention provides apneumostoma management system which includes a partially-implantablepneumostoma vent, a chest mount and drug delivery device. The chestmount is secured to the skin of the patient. The partially-implantablepneumostoma vent is placed into a pneumostoma through an aperture in thechest mount. The drug delivery device attaches to the pneumostoma ventwhile it is mounted in the chest mount.

In accordance with embodiments of the present invention the drugdelivery device provides a therapeutic agent in a vapor, aerosolizedsolution, suspended powder. The therapeutic agent is then introducedinto the pneumostoma using a pressure differential between the drugdelivery device and the pneumostoma. In some cases a positive pressuremay be applied by the drug delivery device. In other cases the drugdelivery device remains at or near ambient pressure and the pressuredifferential is the result of reduced pressure in the pneumostoma duringinhalation by the patient.

In accordance with a specific embodiment of the present inventionprovides a therapeutic agent delivery device which includes: a tubehaving a proximal end and a distal end adapted to be inserted into apneumostoma; an aperture in the distal end of the tube adapted torelease the at least a portion of the therapeutic agent suspended in agas into the pneumostoma; a flange connected to the tube to limitinsertion of the tube into the pneumostoma; a container selectablyconnectable to the proximal end of the tube and adapted to include oneor more doses of the therapeutic agent; and an actuator which is adaptedto release at least a portion of the therapeutic agent and provide theat least a portion of the therapeutic agent suspended in a gas into theproximal end of the tube. Actuation of the actuator provides thetherapeutic agent into via the tube into the pneumostoma.

Thus, various systems, components and methods are provided for managinga pneumostoma and thereby treating COPD. Other objects, features andadvantages of the invention will be apparent from drawings and detaileddescription to follow.

BRIEF DESCRIPTION OF THE DRAWINGS

The above and further features, advantages and benefits of the presentinvention will be apparent upon consideration of the present descriptiontaken in conjunction with the accompanying drawings.

FIG. 1A shows the chest of a patient indicating alternative locationsfor a pneumostoma that may be managed using the device and methods ofthe present invention.

FIG. 1B shows a sectional view of the chest illustrating therelationship between the pneumostoma, lung and natural airways.

FIG. 1C shows a detailed sectional view of a pneumostoma.

FIG. 2A shows a perspective view of components of a pneumostomamanagement device according to an embodiment of the present invention.

FIG. 2B shows a sectional view of the pneumostoma management device ofFIG. 2A partially implanted in a pneumostoma.

FIG. 2C shows a perspective view of a drug delivery device designed tooperate with the pneumostoma management device of FIGS. 2A and 2Baccording to an embodiment of the present invention.

FIG. 2D shows a sectional view of the drug delivery device of FIG. 2Cmated with the pneumostoma management device of FIGS. 2A and 2Baccording to an embodiment of the present invention.

FIG. 2E shows a positioning of a pneumostoma management device and drugdelivery device relative to the chest of a patient.

FIG. 2F shows steps for using a drug delivery device according to anembodiment of the present invention.

FIG. 3A shows a perspective view of an alternative drug delivery deviceaccording to an embodiment of the present invention.

FIG. 3B shows a sectional view of the drug delivery device of FIG. 3A.

FIGS. 4A and 4B show sectional views of an alternative drug deliverydevice according to an embodiment of the present invention.

FIG. 5A shows a top view of an alternative drug delivery deviceaccording to an embodiment of the present invention.

FIG. 5B shows a side view of the drug delivery device of FIG. 5A.

FIG. 6 shows a drug delivery device for use in conjunction with anebulizer.

FIGS. 7A and 7B show views of an alternative drug delivery deviceaccording to an embodiment of the present invention.

FIG. 8A shows a perspective view of a drug delivery device designed tooperate with the pneumostoma management device of FIGS. 2A and 2Baccording to an alternate embodiment of the present invention.

FIG. 8B shows a sectional view of the drug delivery device of FIG. 8Amated with the pneumostoma management device of FIGS. 2A and 2B.

FIG. 8C shows steps for using a drug delivery device such as shown inFIG. 8A.

FIGS. 9A and 9B show sectional views of an alternative drug deliverydevice according to an embodiment of the present invention.

FIG. 10A shows a view of a spirometry system for assessing thefunctionality of a pneumostoma according to an embodiment of the presentinvention.

FIG. 10B shows a view of a gas analysis system for assessing thefunctionality of a pneumostoma according to an embodiment of the presentinvention.

FIG. 10C shows a view of lung imaging system for imaging gas diffusionfrom a pneumostoma according to an embodiment of the present invention.

FIGS. 10D and 10E show views of a diagnostic device for deliveringdiagnostic gas to a pneumostoma or sampling gas from a pneumostomaaccording to embodiments of the present invention.

FIGS. 11A-11C show views of a pneumostoma management device whichprovides a therapeutic agent to the pneumostoma.

FIGS. 11D and 11E show vies of a pneumostoma management device havingdrug infusion features.

DETAILED DESCRIPTION OF THE INVENTION

The following description is of the best modes presently contemplatedfor practicing various embodiments of the present invention. Thedescription is not to be taken in a limiting sense but is made merelyfor the purpose of describing the general principles of the invention.The scope of the invention should be ascertained with reference to theclaims. In the description of the invention that follows, like numeralsor reference designators will be used to refer to like parts or elementsthroughout. In addition, the first digit of a reference numberidentifies the drawing in which the reference number first appears.

Pneumostoma Formation and Anatomy

FIG. 1A shows the chest of a patient identifying alternative locationsfor creating a pneumostoma that may be managed using the system of thepresent invention. A first pneumostoma 110 is shown on the front of thechest 100 over the right lung 101 (shown in dashed lines). Thepneumostoma is preferably positioned over the third intercostal space onthe mid-clavicular line. Thus the pneumostoma 110 is located on thefront of the chest between the third and fourth ribs. Although thepneumostoma 110 is preferably located between two ribs, in alternativeprocedures a pneumostoma can also be prepared using a minithoracotomywith a rib resection.

In FIG. 1A a second pneumostoma 112 is illustrated in a lateral positionentering the left lung 103 (shown in dashed lines). The pneumostoma 112is preferably positioned over the fourth or fifth intercostal spaceunder the left arm 104. In general, one pneumostoma per lung is created;however, more or less than one pneumostoma per lung may be createddepending upon the needs of the patient. In most humans, the lobes ofthe lung are not completely separate and air may pass between the lobes.

A pneumostoma is surgically created by forming an artificial channelthrough the chest wall and joining that channel with an opening throughthe visceral membrane of the lung into parenchymal tissue of the lung toform an anastomosis. The anastomosis is joined and sealed by sealing thechannel from the pleural cavity using adhesives, mechanical sealingand/or pleurodesis. Methods for forming the channel, opening,anastomosis and pleurodesis are disclosed in applicant's pending andissued patents and applications including U.S. patent application Ser.No. 10/881,408 entitled “Methods and Devices to Accelerate Wound Healingin Thoracic Anastomosis Applications,” U.S. patent application Ser. No.12/030,006 entitled “Variable Parietal/Visceral Pleural Coupling,” andU.S. Provisional Patent Application Ser. No. 61/038,371 entitled“Surgical Procedure And Instrument To Create A Pneumostoma And TreatChronic Obstructive Pulmonary Disease” which are incorporated herein byreference in their entirety.

FIG. 1B shows a sectional view of chest 100 illustrating the position ofthe pneumostoma 110. The parenchymal tissue 132 of the lung 130 iscomprised principally of alveoli 134. The alveoli 134 are the thinwalled air-filled sacs in which gas exchange takes place. Air flows intothe lungs through the natural airways including the trachea 136, carina137, and bronchi 138. Inside the lungs, the bronchi branch into amultiplicity of smaller vessels referred to as bronchioles (not shown).Typically, there are more than one million bronchioles in each lung.Each bronchiole connects a cluster of alveoli to the natural airways. Asillustrated in FIG. 1B, pneumostoma 110 comprises a channel through thethoracic wall 106 of the chest 100 between two ribs 107. Pneumostoma 110opens at an aperture 126 through the skin 114 of chest 100.

FIG. 1C shows a detailed sectional view of the pneumostoma 110. Asillustrated in FIG. 1C, pneumostoma 110 comprises a channel 120 throughthe thoracic wall 106 of the chest 100 between the ribs 107. The channel120 is joined to cavity 122 in the parenchymal tissue 132 of lung 130.An adhesion or pleurodesis 124 surrounds the channel 120 where it entersthe lung 130. The thoracic wall 106 is lined with the parietal membrane108. The surface of the lung 130 is covered with a continuous sac calledthe visceral membrane 138. The parietal membrane 108 and visceralmembrane 138 are often referred to collectively as the pleuralmembranes. Between the parietal membrane 108 and visceral membrane 138is the pleural cavity (pleural space) 140. The pleural cavity usuallyonly contains a thin film of fluid that serves as a lubricant betweenthe lungs and the chest wall. In pleurodesis 124 the pleural membranesare fused and/or adhered to one another eliminating the space betweenthe pleural membranes in that region.

An important feature of the pneumostoma is the seal or adhesionsurrounding the channel 120 where it enters the lung 130 which maycomprise a pleurodesis 124. Pleurodesis 124 is the fusion or adhesion ofthe parietal membrane 108 and visceral membrane 138. A pleurodesis maybe a complete pleurodesis in which the entire pleural cavity 140 isremoved by fusion of the visceral membrane 138 with the parietalmembrane 108 over the entire surface of the lung 130. However, as shownin FIG. 1C, pleurodesis 124 is preferably localized to the regionsurrounding the channel 120. The pleurodesis 124 surrounding the channel120 prevents air from entering the pleural cavity 140. If air ispermitted to enter pleural cavity 140, a pneumothorax will result andthe lung may collapse.

Pleurodesis 124 can be created between the visceral pleura of the lungand the inner wall of the thoracic cavity using chemical methodsincluding introducing into the pleural space irritants such asantibiotics (e.g. Doxycycline or Quinacrine), antibiotics (e.g.iodopovidone or silver nitrate), anticancer therapeutic agents (e.g.Bleomycin, Mitoxantrone or Cisplatin), cytokines (e.g. interferonalpha-2β and Transforming growth factor-β); pyrogens (e.g.Corynebacterium parvum, Staphylococcus aureus superantigen or OK432);connective tissue proteins (e.g. fibrin or collagen) and minerals (e.g.talc slurry). A pleurodesis can also be created using surgical methodsincluding pleurectomy. For example, the pleural space may bemechanically abraded during thoracoscopy or thoracotomy. This procedureis called dry abrasion pleurodesis. A pleurodesis may also be createdusing radiotherapy methods, including radioactive gold or externalradiation. These methods cause an inflammatory response and or fibrosis,healing, and fusion of the pleural membranes. Alternatively, a seal canbe created in an acute manner between the pleural membranes usingbiocompatible glues, meshes or mechanical means such as clamps, staples,clips and/or sutures. The adhesive or mechanical seal may develop intopleurodesis over time. A range of biocompatible glues are available thatmay be used on the lung, including light-activatable glues, fibringlues, cyanoacrylates and two part polymerizing glues. Applicant'scopending U.S. patent application Ser. No. 12/030,006 entitled “VARIABLEPARIETAL/VISCERAL PLEURAL COUPLING” discloses methods such aspleurodesis for coupling a channel through the chest wall to the innervolume of the lung without causing a pneumothorax and is incorporatedherein by reference for all purposes.

When formed, pneumostoma 110 provides an extra pathway for exhaled airto exit the lung 130 reducing residual volume and intra-thoracicpressure without the air passing through the major natural airways suchas the bronchi 138 and trachea 136. Collateral ventilation isparticularly prevalent in an emphysematous lung because of thedeterioration of lung tissue caused by COPD. Collateral ventilation isthe term given to leakage of air through the connective tissue betweenthe alveoli 134. Collateral ventilation may include leakage of airthrough pathways that include the interalveolar pores of Kohn,bronchiole-alveolar communications of Lambert, and interbronchiolarpathways of Martin. This air typically becomes trapped in the lung andcontributes to hyperinflation. In lungs that have been damaged by COPDand emphysema, the resistance to flow in collateral channels (not shown)of the parenchymal tissue 132 is reduced allowing collateral ventilationto increase. Air from alveoli 134 of parenchymal tissue 132 that passesinto collateral pathways of lung 130 is collected in cavity 122 ofpneumostoma 110. Pneumostoma 110 thus makes use of collateralventilation to collect air in cavity 122 and vent the air outside thebody via channel 120 reducing residual volume and intra-thoracicpressure and bypassing the natural airways which have been impaired byCOPD and emphysema.

By providing this ventilation bypass, the pneumostoma allows stale airtrapped in the parenchymal tissue 132 to escape from the lung 130. Thisreduces the residual volume and intra-thoracic pressure. The lowerintra-thoracic pressure reduces the dynamic collapse of airways duringexhalation. By allowing the airways to remain patent during exhalation,labored breathing (dyspnea) and residual volume (hyperinflation) areboth reduced. Pneumostoma 110 not only provides an extra pathway thatallows air to exit the lung 130 but also allows more fresh air to bedrawn in through the natural airways. This increases the effectivenessof all of the tissues of the lung 130 and improves gas exchange.Pneumostoma 110 thus achieves many of the advantages sought by lungvolume reduction surgery without surgically removing a portion of thelung or sealing off a portion of the lung.

U.S. Pat. No. 7,398,782 titled “Pulmonary Drug Delivery” to Tanakadiscusses the local delivery of therapeutic agents directly into thelungs for treating various disease conditions and is incorporated hereinby reference. As disclosed herein, a pneumostoma management system inaccordance with embodiments of the present invention is advantageous tomaintain the patency of a pneumostoma and control flow of materialsbetween the exterior of the patient and the parenchymal tissue of thelung via a pneumostoma. The pneumostoma management system includes apneumostoma management device and a drug delivery device.

Pneumostoma Management System Including Drug Delivery Device

As described above, a pneumostoma may be created to treat the symptomsof chronic obstructive pulmonary disease. A patient is typicallyprovided with a pneumostoma management device to protect the pneumostomaand keeps the pneumostoma open on a day-to-day basis. In general terms apneumostoma management device (“PMD”) comprises a tube which is insertedinto the pneumostoma and an external component which is secured to theskin of the patient to keep the tube in place. Gases escape from thelung through the tube and are vented external to the patient. Thepneumostoma management device may, in some, but not all cases, include afilter which only permits gases to enter or exit the tube. Thepneumostoma management device may, in some, but not all cases, include aone-way valve which allows gases to exit the lung but not enter the lungthrough the tube.

FIGS. 2A through 2E illustrate views of a pneumostoma management systemincluding a pneumostoma management device (“PMD”) 201 and a drugdelivery device 260 in accordance with an embodiment of the presentinvention. The drug delivery device 260 is shown in FIGS. 2C, 2D and 2E.As shown in FIGS. 2A and 2B, PMD 201 includes a chest mount 202 whichmay be mounted to the skin of the patient and a pneumostoma vent 204which is fitted to the chest mount 202. In a preferred embodimentpneumostoma vent 204 is mounted through an aperture 224 in chest mount202. Chest mount 202 has a first coupling that engages a second couplingof the pneumostoma vent to releasably secure the pneumostoma vent 204 tothe chest mount 202. The join between the two components of PMD 201 isengineered to ensure that pneumostoma vent 204 cannot be over-insertedinto the lung if it separates from chest mount 202. Applicant's relatedpatent applications referenced above provide further description ofpneumostoma management devices and are incorporated herein by referencein its entirety.

Referring now to FIG. 2B, pneumostoma vent 204 includes a tube 240 sizedand configured to fit within the channel of a pneumostoma 110. Tube 240is stiff enough that it may be inserted into a pneumostoma withoutcollapsing. Over time a pneumostoma may constrict and it is one functionof PMD 201 to preserve the patency of the channel of the pneumostoma byresisting the natural tendency of the pneumostoma to constrict. Tube 240of pneumostoma vent 204 preferably comprises an atraumatic tip 252 atthe distal end as shown in FIGS. 2A and 2B. (This application uses theterms proximal and distal regarding the components of the pneumostomamanagement system in the conventional manner. Thus, proximal refers tothe end or side of a device closest to the hand operating the device,whereas distal refers to the end or side of a device furthest from thehand operating the device.) Tip 252 may be rounded, beveled or curved inorder to reduce irritation or damage to the tissues of the pneumostomaor lung during insertion or while in position. Opening 254 in tip 252allows the entry of gases from the cavity of the pneumostoma 110 intolumen 258 of tube 240. Tube 240 is optionally provided with one or moreside openings (not shown) positioned near tip 252 and/or along thelength of tube 240 to facilitate the flow of gas and/or mucous/dischargeinto lumen 258.

Tube 240 of pneumostoma vent 204 is sufficiently long that it can passthrough the thoracic wall and into the cavity of a pneumostoma insidethe lung. Pneumostoma vent 204 is not however so long that it penetratesso far into the lung that it might cause injury. The material andthickness of tube 240 of pneumostoma vent 204 is selected such that tube240 is soft enough that it will deform rather than cause injury to thepneumostoma or lung. Pneumostoma vent 204 has an opening 254 in tip 252of tube 240. The length of tube 240 required for a pneumostoma vent 204varies significantly between different pneumostomas. A longer tube 240is usually required in patients with larger amounts of body fat on thechest. A longer tube 240 is usually required where the pneumostoma isplaced in the lateral position 112 rather than the frontal position 110.Because of the variation in pneumostomas, pneumostoma vents 204 aremanufactured having tubes 240 in a range of sizes and a patient isprovided with a pneumostoma vent 204 having a tube 240 of appropriatelength for the patient's pneumostoma. Tube 240 may be from 30 to 120 mmin length and from 5 mm to 20 mm in diameter depending on the size of apneumostoma. A typical tube 240 may be between 40 mm and 80 mm in lengthand between 8 mm and 12 mm in diameter. In alternative embodiments, apneumostoma vent 204 is made with a single length (such as 120 mm) oftube 240 and tube 240 is then cut to the length appropriate for aparticular patient. Where a single length tube 240 is provided andsubsequently cut to length it is desirable that the tube be shaped suchthat at each of a plurality of cut points cutting will generate anatraumatic tip. This can be achieved, for example, by including a seriesof rounded narrow points on tube 240.

Pneumostoma vent 204 includes a cap 242 and a hydrophobic filter 248over the opening 255 in the proximal end of tube 240. Hydrophobic filter248 is positioned over the proximal opening 255 into lumen 258.Hydrophobic filter 248 is positioned and mounted such that materialmoving between lumen 258 and the exterior of pneumostoma vent 204 mustpass through hydrophobic filter 248. Hydrophobic filter 248 ispreferably designed such to fit into a recess in cap 242. As shown inFIG. 2B, cap 242 comprises a recess 238 into which hydrophobic filter248 may be fit. Hydrophobic filter 248 may alternatively be fitted intocap 242 using a joint such as a threaded coupling or adhesive or, insome cases, formed integrally with cap 242. Hydrophobic filter 248 maybe made from a material such as medical grade GOR-TEX (W. L. Gore &Associates, Inc., Flagstaff, Ariz.). As shown in FIG. 2B, a snap ring243 locks cap 242 and hydrophobic filter 248 onto the proximal end oftube 240.

Hydrophobic filter 248 serves several purposes. In general, hydrophobicfilter 248 controls the passage of solid or liquid material between thelumen 258 and the exterior of cap 242. For example, hydrophobic filter248 prevents the flow of water into the lumen 258 through proximalopening 255. Thus, a patient using PMD 201 may shower without waterentering the lung through the pneumostoma. Hydrophobic filter 248 mayalso be selected so as to prevent the entry of microbes, pollen andother allergens and pathogens into the lumen 258. Hydrophobic filter 248also prevents the exit of liquid and particulate discharge from lumen258 to the exterior of pneumostoma vent 204. This is desirable toprevent contact between liquid and particulate discharge and clothingfor example.

Chest mount 202 connects to the proximal end of pneumostoma vent 204. Inone embodiment, illustrated in FIGS. 2A and 2B, chest mount 202comprises a flange 222 and an aperture 224. The aperture 224 is adaptedand configured to receive the pneumostoma vent 204. Chest mount 202 isdesigned to have a smooth surface and a low profile so it is comfortablefor the patient to wear. Chest mount 202 should be designed so as not tosnag on the patient's clothing or to restrict motion of the patient'sarm (if placed in a lateral pneumostoma 112). Flange 222 issignificantly wider than pneumostoma vent 204. Flange 222 thus comprisesa contact surface 232 which contacts the skin of the patient surroundingthe pneumostoma and positions the aperture 224 over the opening of thepneumostoma. Flange 222 is designed such that it is sufficientlyflexible that it can conform to the surface of the chest. Contactsurface 232 is also provided with a pad of biocompatible adhesive 234,such as a hydrocolloid adhesive, for securing flange 222 to the skin ofthe patient. The adhesive 234 may be protected by a protector sheet thatis removed prior to use of flange 222. Adhesive 234 should be selectedso as to secure flange 222 to the chest of the patient in the correctposition relative to the pneumostoma without causing undue irritation tothe skin of the patient. The adhesive need not create an air tight sealbetween flange 222 and the skin of the patient. Suitable adhesive padsare available commercially from Avery Dennison (Painesville, Ohio).

Referring again to FIGS. 2A and 2B, cap 242 is attached to the proximalend of tube 240. Hydrophobic filter 248 is sandwiched between cap 242and tube 240. An opening 244 in cap 242 communicates with the lumen 258of tube 240 via hydrophobic filter 248. As shown in FIGS. 2A and 2B, cap242 comprises a lip 246 which releasably engages lip 227 of recess 226of flange 222 to secure pneumostoma vent 204 within the recess 226 offlange 222. Lip 246 forms a coupling element of pneumostoma vent 204that cooperates with recess 226 to releasably secure pneumostoma vent204 into chest mount 202 with tube 240 positioned through aperture 224.

Referring again to FIGS. 2A and 2B, flange 222 is generally circular butis provided with one or more tabs 236 to facilitate application andremoval of flange 222 from the skin of the patient. Chest mount 202comprises an aperture 224 through which tube 240 of pneumostoma vent 204may be inserted. Flange 222 is slightly convex on the upper surface 235.Flange 222 includes a recess 226 into which cap 242 of pneumostoma vent204 may be press fit. Flange 222 is thick enough in the region ofaperture 224 to receive the cap 242 of pneumostoma vent 204 so that thecap of pneumostoma vent 204 is flush with the upper surface 235 offlange 222. Recess 226 forms a coupling adapted to releasably secure thecap 242 of pneumostoma vent 204 into flange 222. Recess 226 has a lip227 to releasably secure the cap 242 of pneumostoma vent 204 into flange222. However, other couplings may be used to releasably securepneumostoma vent 204 to chest mount 202 including clips, pins, snaps,catches, threaded joints, temporary adhesive and the like.

In a preferred embodiment, an aperture plate 228 is embedded in theconformable polymer of flange 222. The aperture plate 228 definesaperture 224 of chest mount 202. Aperture plate 228 is made of astiffer, less compliant material than flange 222 in order that thedimensions of aperture 224 are tightly controlled. Aperture plate 228 isstiff enough that the size and shape of aperture 224 remains stable evenunder any reasonably possible application of force to chest mount 202.It should be noted that the outer diameter of each of snap ring 243,hydrophobic filter 248, flange 241 and cap 242 is larger than thediameter of aperture 224 of aperture plate 228. Thus, snap ring 243,hydrophobic filter 248, flange 241 and cap 242 cannot pass throughaperture 224 into the pneumostoma 110. Distal tip 252 of tube 240 andthe body of tube 240 are small enough to pass through aperture 224however, flange 241 and/or cap 242 serve to limit the passage of tube240 through aperture 224. These safety features prevent unsafe entry ofany of the components of pneumostoma vent 204 into pneumostoma even inthe unlikely event of damage to the device. Likewise all the componentsof the chest mount 202 such as flange 222 and aperture plate 224 aresignificantly larger than the aperture of a pneumostoma thus precludingpassage of any component of the chest mount 202 into a pneumostoma evenin the unlikely event of damage to the device.

Referring now to FIGS. 2C and 2D which show views of a drug deliverydevice 260 designed to be used in conjunction with PMD 201 of FIGS. 2Aand 2B as part of a pneumostoma management system. FIG. 2C shows aperspective view of drug delivery device 260. FIG. 2D shows a sectionalview through drug delivery device 260 of FIG. 2C when mounted in a chestmount 202. As shown in FIGS. 2C and 2D, drug delivery device 260includes a therapeutic agent dispenser 262, a coupling 264 and a tube266. Drug delivery device 260 is configured such that tube 266 may beinserted through aperture 224 of chest mount 202 into pneumostoma 110.Tube 266 is sufficiently long to enter the pneumostoma but is not solong that it might cause injury to the pneumostoma. Coupling 264 isdesigned such that it is too large to pass through aperture 224 of chestmount 202 thereby preventing further insertion of tube 266 intopneumostoma 110. Coupling 264 may optionally be provided with a featuresuch as a lip 265 for releasably engaging lip 227 of recess 228 of chestmount 202. A range of drug delivery devices may be manufactured eachhaving a size appropriate for a different pneumostoma.

To simplify manufacture, drug delivery device 260 may be designed to usesome components in common with pneumostoma vent 240. For example, therange of tubes 240 of the pneumostoma vent may be used as tube 266 ofdrug delivery device 260. Alternatively it may be preferable to makedrug delivery device with only one size of tube 266 and thus theshortest of tubes 240 may be selected for use in drug delivery device260. In some embodiments, the snap ring 243 may also be a sharedcomponent 264. The distal end of coupling 264 is shaped similarly to cap242 and thus the snap ring 243 can join tube 266 to coupling 264 in thesame manner as tube 240 is coupled to cap 242. Also the exterior surfaceof the distal end of coupling 264 engages chest mount 202 in the sameway as cap 242. This simplifies the manufacturing and regulatory processfor drug delivery device 260.

Therapeutic agent dispenser 262 includes a mechanism for providing anaerosol, mist or powder in suspended in a propellant gas undersufficient positive pressure to enter the lung through the tube. Thetherapeutic agent dispenser preferably provides positive pressure topush the therapeutic agent into the pneumostoma. Suitable therapeuticagent dispenser mechanisms for providing metered doses of therapeuticagents in a propellant gas are known. Suitable therapeutic agentdispensers include therapeutic agent dispensing mechanisms found innebulizers, ultrasonic nebulizers, metered dose inhalers and dry powderinhalers. Dry powder therapeutic agent dispensers deliver a finemicrocrystalline suspension of therapeutic agent. In the example shownin FIGS. 2C, 2D a pressurized canister 268 is received in sleeve 270.The outlet valve 269 of canister 268 engages a fixture 272 in the bottomof sleeve 270. When the user pushes canister 268 down into sleeve 270,fixture 272 activates valve 269 to release a metered dose of therapeuticagent in a propellant gas. The therapeutic agent and propellant gas passthrough a channel 274 in fixture 270 and are ejected into and throughtube 266 as shown by arrow 276.

Note that in some embodiments it is unnecessary for therapeutic agentdispenser 262 to provide a propellant gas at positive pressure tointroduce the aerosol, mist or powder into the lung through thepneumostoma. In some embodiments the therapeutic agent dispenser 262provides the therapeutic agent/gas mixture at or near ambient pressure.Reduced pressure in the pneumostoma during inhalation by the patientcreates a pressure differential which sucks the therapeutic agentsuspended in air/ gas into the pneumostoma.

FIG. 2E illustrates the positioning of drug delivery device 260 overpneumostoma 112 of FIG. 1A. In a preferred embodiment, the chest mount202 remains attached for up to a week thereby avoiding irritation of theskin caused by daily attachment and removal of a mount. Chest mount maybe positioned by the patient by manual alignment of the aperture 224 ofchest mount 202 with the aperture of the pneumostoma 112. To use drugdelivery device 260, chest mount 202 is first positioned over apneumostoma and secured with adhesive to the skin of the patient.Alternatively a pneumostoma vent or an alignment tool may be used toalign the chest mount. Drug delivery device 260 is then inserted throughthe aperture in the chest mount until it engages the chest mount 202. Asshown in FIG. 2E, the drug delivery device 260 is inserted through chestmount 202 after pneumostoma vent 204 has been removed. Drug deliverydevice 260 is then operated to supply the aerosolized or dry powdertherapeutic agent directly to the parenchymal tissue of the lung throughpneumostoma 112 by operation of therapeutic agent dispenser 262 eitherby the patient, caregiver or medical practitioner.

FIG. 2F shows an example of a method of using a drug delivery deviceaccording to embodiments of the present invention. The method may bedescribed in instructions for use provided to the patient with the drugdelivery device. At step 280, the patient adjusts the pneumostomamanagement device. Depending on the operation of the drug deliverydevice, this step may involve, for example, removing a component of thepneumostoma vent such as the filter; removing the entire pneumostomavent; or removing the entire pneumostoma management device. At step 282,the patient positions the drug delivery device in the pneumostoma. Insome embodiments this step will involve connecting the pneumostomamanagement device to a tube already positioned in the pneumostoma. Atstep 484, the patient loads a dose of the therapeutic agent into thedrug delivery device. In some cases, the therapeutic agent is providedin single dose containers and thus this will involve loading a singledose package or indexing a package containing multiple singe dosecontainers to a full container. In other cases, the therapeutic agentwill be in a multiple-use container, such as a pressurized metered dosecanister and it will be unnecessary for the patient to load atherapeutic agent dose unless the container is empty. The drug deliverydevice is now prepared for operation.

In a typical therapeutic agent delivery operation the patient will firstexhale through the nose/mouth at step 285 immediately prior to actuatingthe drug delivery device. At step 286 the drug delivery device isactuated to mix the therapeutic agents (aerosol, gas or dry powder) inthe propellant/air. In some embodiments this mixing step requires arelatively high air speed/pressure. It may be undesirable for thisairspeed/pressure to be applied to the pneumostoma and thus the locationof mixing step 286 may be separated by features to reduce theairspeed/pressure distance before the mixture reaches the pneumostoma.Such features may include, for example, space, volume, baffles and thelike. At step 288 application of positive pressure is used to propel themixture of therapeutic agent and propellant into the pneumostoma and/orthrough the pneumostoma into the lung. The positive pressure applied atthis step may be substantially less than the pressure used at step 286.The positive pressure may be supplied by a different mechanism or by amodulation of the same mechanism. Steps 286 and 288 may be combined inone step for example where the pressure is modulated by the mechanics ofthe device such that a higher local pressure is available in one part ofthe device to mix the agent but is reduced by the time it reaches thepneumostoma. Note that in some embodiments it is unnecessary for thetherapeutic agent dispenser to provide propellant gas at positivepressure to introduce the aerosol, mist or powder into the lung throughthe pneumostoma. In some embodiments the drug delivery device remains ator near ambient pressure and reduced pressure in the pneumostoma duringinhalation by the patient creates a pressure differential which sucksthe aerosol, mist or powder suspended in air/ gas into the pneumostoma.

At step 290, air is introduced through the pneumostoma to aiddistribution of the therapeutic agent through the lung tissue bycollateral ventilation. Step 290 is optional and may in some cases becombined with step 288. In some cases step 290 may be achieved by thepatient “inhaling” through the pneumostoma in which the patient expandsthe ribcage thereby creating a negative pressure in the chest to drawair in through the pneumostoma. In some circumstances this “inhalation”through the pneumostoma may be enhanced by obstructing the nose andmouth while expanding the ribcage. However, step 290 may not benecessary and a therapeutic agent may be efficiently distributed fromthe pneumostoma through parenchymal tissue of the lung by collateralventilation without the need for additional intake of air through thepneumostoma.

At step 292, the patient optionally holds their breath for a time priorto exhaling, such as 10 to 15 seconds. This step may not be necessaryfor therapeutic agents delivered into the pneumostoma. Because thetherapeutic agent was not delivered through the natural airways, it willnot be rapidly exhaled through the natural airways. Indeed, in somecases breathing normally (while obstructing the pneumostoma) while causerapid distribution of the therapeutic agent through the lung with littleloss of therapeutic agent due to exhalation. In some case it may beadvantageous to provide a slight positive pressure of air to thepneumostoma after delivery of the therapeutic agent to promote diffusionof the therapeutic agent through the lung. Steps 284 and 292 may berepeated a number of times if necessary to deliver multiple doses oftherapeutic agent as shown by dashed arrow 294.

It may be desirable to leave the drug delivery device in place for aperiod after delivery of therapeutic agent to prevent the agent frombeing ejected through the pneumostoma. After the therapeutic agent hasbeen delivered, the drug delivery device is removed from the pneumostomaat step 296. In some cases the drug delivery device may be detached fromthe pneumostoma vent of chest mount. At step 298, the pneumostomamanagement device is replaced into the pneumostoma. Alternatively, anyremoved components of the pneumostoma management device are reattached.Any or all of the above steps may be performed and/or controlled by aphysician or caregiver instead of the patient. The therapeutic agentdelivery steps may be repeated according to a particular dosing scheduleor as needed depending on the therapeutic agent and/or physician'sinstructions.

Therapeutic Agents for Delivery Through a Pneumostoma

The present invention provides a drug delivery device which delivers atherapeutic agent into the lung 130 without passing through the mouthand the major natural airways such as the bronchi 138 and trachea 136.For inhaled therapeutic agents, a significant fraction of thetherapeutic agent may be deposited in the upper respiratory tract andmay cause unwanted side effects. For example, inhalation ofcorticosteroids to reduce inflammation, can suppress the immune systemin the mouth leading to infections. Additionally, the amount oftherapeutic agent reaching the lung can vary depending upon theabilities of the patient to use the inhaler. In the present invention amuch larger fraction of the therapeutic agent is delivered directly tothe lung. Moreover, the therapeutic agent is circulated in the lung, atleast in part, using collateral ventilation through the connectivetissue between the alveoli 134. Collateral ventilation is particularlyprevalent in an emphysematous lung because of the deterioration of lungtissue caused by COPD. Collateral ventilation may distribute thetherapeutic agent through pathways that include the interalveolar poresof Kohn, bronchiole-alveolar communications of Lambert, andinterbronchiolar pathways of Martin. This may provide better and/or moredirect access to the damaged tissues of the lung than is possiblethrough the natural airways.

The dosage of a particular therapeutic agent required to be delivered bythe pneumostoma will, in many cases, be significantly less than thedosage that would be required to be delivered by the natural airways forthe same therapeutic effect. The lower dose can be used because thetherapeutic agent delivered through the pneumostoma is not trapped inthe natural airways by the body's natural defenses against particulatesin the air. Not only does a higher fraction of therapeutic agent reachthe lung tissue but the variability of drug delivery is also less. Thelower dosage required for delivery through the pneumostoma isadvantageous as it reduces the amount and therefore cost of thetherapeutic agent, reduces side effects to the patient, and rendersdosing more consistent.

As used herein, therapeutic agents may be solid, liquid (includingsolutions and suspensions), and/or gas. In general, there are threetypes of therapeutic agents that may be delivered using the methods anddevices of the present invention: therapeutic agents to treat thetissues of the pneumostoma; therapeutic agents to treat tissue withinthe lung; and therapeutic agents to treat diseases that are notlung-specific.

For treatment of the pneumostoma, the therapeutic agent has the shortestdistance to travel. The therapeutic agent is distributed utilizingabsorption and diffusion through the pneumostoma and into lungparenchymal tissue adjacent the pneumostoma. Parameters of the deliverymay be selected so that the therapeutic agent is selectively absorbed inthe immediate vicinity of the pneumostoma. For example, thedroplet/powder size may be increased and/or the amount of propellantdecreased to reduce transport of the agent away from the pneumostoma.Therapeutic agents for treating the pneumostoma may include, withoutlimitation, agents to promote healing, agents to reduce scarring, agentsto maintain the patency of the pneumostoma; agents to prevent infection;agents to maintain the collateral ventilation into/from the pneumostoma.Suitable therapeutic agents may have an anti-inflammatory and/orantiproliferative and/or spasmolytic and/or endothelium-forming effect,so that the functionality of the pneumostoma is maintained. Suitabletherapeutic agents may include, for example, steroidal compounds;antibiotics and retinoic acid.

For treatment of the tissue within the lung, the therapeutic agent isdistributed utilizing collateral ventilation, absorption and diffusionthrough the lung tissues. Parameters of the delivery may be selected sothat the therapeutic agent is readily transported via collateralchannels. For example, the droplet/powder size may be decreased and/orthe amount of propellant increased to enhance transport of the agentthrough collateral channels. The therapeutic agents can include agentswhich work directly on the bronchiole mucosa and smooth muscle when usedproperly. For example bronchospasm is a major component COPD whichlimits airflow. Bronchospasm can be relieved by bronchodilatortherapeutic agent including, without limitation, beta-2 adrenergicagonists and anti-cholinergic therapeutic agents. The followingtherapeutic agents may be particularly suitable as they are commonlyused for treatment of COPD: albuterol, chromolyn, salbuterol,metaproterenol, pirbuterol, salmeterol, formoterol, ipratropium,tiotropium, flucatisone, budesonide, flunisolide, beclamethasone,triamcinolone, mometasone or combinations and analogs thereof.

Other agents suitable for treating the lung tissue include, withoutlimitation: anti-proliferative/antimitotic agents including naturalproducts such as vinca alkaloids (i.e. vinblastine, vincristine, andvinorelbine), paclitaxel, epidipodophyllotoxins (i.e. etoposide,teniposide), antibiotics (dactinomycin (actinomycin D) daunorubicin,doxorubicin and idarubicin), anthracyclines, mitoxantrone, bleomycins,plicamycin (mithramycin) and mitomycin, enzymes (L-asparaginase whichsystemically metabolizes L-asparagine and deprives cells which do nothave the capacity to synthesize their own asparagine); antiplateletagents such as G(GP) IIb/IIIa inhibitors and vitronectin receptorantagonists; anti-proliferative/antimitotic alkylating agents such asnitrogen mustards (mechlorethamine, cyclophosphamide and analogs,melphalan, chlorambucil), ethylenimines and methylmelamines(hexamethylmelamine and thiotepa), alkyl sulfonates-busulfan,nirtosoureas (carmustine (BCNU) and analogs, streptozocin),trazenes-dacarbazinine (DTIC); anti-proliferative/antimitoticantimetabolites such as folic acid analogs (methotrexate), pyrimidineanalogs (fluorouracil, floxuridine, and cytarabine), purine analogs andrelated inhibitors (mercaptopurine, thioguanine, pentostatin and2-chlorodeoxyadenosine{cladribine}); platinum coordination complexes(cisplatin, carboplatin), procarbazine, hydroxyurea, mitotane,aminoglutethimide; hormones (i.e. estrogen); anti-coagulants (heparin,synthetic heparin salts and other inhibitors of thrombin); fibrinolyticagents (such as tissue plasminogen activator, streptokinase andurokinase), aspirin, dipyridamole, ticlopidine, clopidogrel, abciximab;antimigratory; antisecretory (breveldin); anti-inflammatory: such asadrenocortical steroids (cortisol, cortisone, fludrocortisone,prednisone, prednisolone, 6a-methylprednisolone, triamcinolone,betamethasone, and dexamethasone), non-steroidal agents (salicylic acidderivatives i.e. aspirin; para-aminophenol derivatives i.e.acetaminophen; indole and indene acetic acids (inaperturethacin,sulindac, and etodalac), heteroaryl acetic acids (tolmetin, diclofenac,and ketorolac), arylpropionic acids (ibuprofen and derivatives),anthranilic acids (mefenamic acid, and meclofenamic acid), enolic acids(piroxicam, tenoxicam, phenylbutazone, and oxyphenthatrazone),anti-asthmatics, nabumetone, gold compounds (auranofin, aurothioglucose,gold sodium thiomalate); immunosuppressives: (cyclosporine, tacrolimus(FK-506), sirolimus (rapamycin), azathioprine, mycophenolate mofetil);angiogenic agents: vascular endothelial growth factor (VEGF), fibroblastgrowth factor (FGF); angiotensin receptor blockers; nitric oxide donors;antisense oligionucleotides and combinations thereof, cell cycleinhibitors, mTOR inhibitors, and growth factor receptor signaltransduction kinase inhibitors; retenoids; cyclin/CDK inhibitors; HMGco-enzyme reductase inhibitors (statins); silver compound and proteaseinhibitors.

The method and devices of the present invention are also useful fordelivery of therapeutic agents for treating diseases which are notlung-specific. In such cases, the pneumostoma and lung tissue areutilized as absorption surfaces through which the agent may enter theblood stream for systemic distribution to all of the tissues of thebody. Parameters of the delivery may be selected so that the therapeuticagent is readily transported via collateral channels in order to beabsorbed over a large surface area additionally, the therapeutic agentshould be selected/treated such that it may readily pass into thebloodstream. In one example, insulin may be delivered to the patientthrough the pneumostoma. The insulin is absorbed within the lung andpasses into the blood where it is effective to control blood sugarlevels. The insulin delivery should be more rapid and reliable thaninhaled or oral insulin delivery methods and avoid the need forinjection of insulin.

Other suitable pharmaceutically-active substances for delivery throughthe pneumostoma include, without limitation: amino acids, anabolics,analgesics and antagonists, anaesthetics, anti-adrenergic agents,anti-atherosclerotics, antibacterials, anticholesterolics,anti-coagulants, antidepressants, antidotes, anti-emetics,anti-epileptic therapeutic agents, anti-fibrinolytics, anti-inflammatoryagents, antihypertensives, antimetabolites, antimigraine agents,antimycotics, antinauseants, antineoplastics, anti-obesity agents,antiprotozoals, antipsychotics, antirheumatics, antiseptics, antivertigoagents, antivirals, appetite stimulants, bacterial vaccines,bioflavonoids, calcium channel blockers, capillary stabilizing agents,coagulants, corticosteroids, detoxifying agents for cytostatictreatment, diagnostic agents (like contrast media, radiopaque agents andradioisotopes), electrolytes, enzymes, enzyme inhibitors, ferments,ferment inhibitors, gangliosides and ganglioside derivatives,hemostatics, hormones, hormone antagonists, hypnotics, immunomodulators,insulin, immunostimulants, immunosuppressants, minerals, musclerelaxants, neuromodulators, neurotransmitters and neurotrophins, osmoticdiuretics, parasympatholytics, para-sympathomimetics, peptides,proteins, psychostimulants, respiratory stimulants, sedatives, serumlipid reducing agents, smooth muscle relaxants, sympatholytics,sympathomimetics, vasodilators, vasoprotectives, vectors for genetherapy, viral vaccines, viruses, vitamins, oligonucleotides andderivatives, saccharides, polysaccharides, glycoproteins, hyaluronicacid, and any excipient that can be used to stabilize a proteinaceoustherapeutic.

The therapeutic agent dosage will depend upon factors including: theintended location of action of therapeutic agent, the efficiency ofdistribution of the therapeutic agent, the repeatability of distributionof the therapeutic agent and the amount/concentration of therapeuticagent necessary for therapeutic action. In general the dosage will befirst determined during trials of the therapeutic agent on a population.Based upon trials, the physician will determine a dose for a particularpatient and prescribe the therapeutic agent and/or delivery protocolaccordingly. For example a physician may prescribe larger sized doses oftherapeutic agent or a larger number of repetitions of dosages toachieve the same total dosage. Therapeutic agent delivery through thepneumostoma requires therapeutic agents to travel a shorter pathway thaninhaled therapeutic agent leading to more efficient and repeatabledistribution. Additionally, the therapeutic agent is not subject tobreakdown by stomach acid and enzymes as it is when delivered via theoral route. The increased efficiency and repeatability of distributionmeans that, in general, less therapeutic agent need be included perdose, enhancing control of the therapeutic effects and reducingside-effects.

Propellants for Delivery of Therapeutic Agents Through a Pneumostoma

In the past, chlorofluorocarbons were the primary substances used aspropellants in aerosols. Since 1978, the use ofchlorofluorocarbon-emitting products in the United States has beencurtailed sharply because of their adverse effects upon the ozone layer.The pharmaceutical industry has developed alternative propellants suchas hydro-fluoroalkanes which are the new environmentally-friendlychemical propellants. Both chlorofluorocarbons and hydro-fluoroalkanesare suitable chemical propellants for use in the present invention.

Lower pressures and flow rates are required for direct delivery oftherapeutic agents to the lung in embodiments of the present inventionthan are needed for delivery via inhalation. This allows for the use ofair at slight positive pressures to be used to propel the therapeuticagent a short distance into the lung. As used herein propellant shouldbe taken to include chemical propellants as well as gases at positivepressure. The air may be provided by a fan, pump, cylinder or bag, forexample which may be operated by a powered actuator or manually. Thepressure of propellant supplied by the device should be carefullycontrolled/regulated to ensure that it does not damage the pneumostomaor lung tissue. In some cases, a safety valve may be provided to allowgas to escape the pneumostoma or drug delivery device if the pressuresupplied to the pneumostoma exceeds a safe threshold. Note that in someembodiments the drug delivery device remains at or near ambient pressureand reduced pressure in the pneumostoma during inhalation by the patientcreates a positive pressure differential which sucks the aerosol, mistor powder suspended in air/ gas into the pneumostoma.

Diagnostic Agents for Delivery Through a Pneumostoma

In alternative embodiments, a diagnostic agent rather than a therapeuticagent may be delivered through the pneumostoma. The diagnostic agent maybe useful for diagnosing lung function in general and pneumostomafunction in particular. For example, polarized Helium-3 may be utilizedto enhance nuclear magnetic resonance/magnetic resonance imaging of thelung (analogous to the way contrast agents enhance X-ray imaging).Polarized helium-3 may be produced with lasers and the magnetizedpressurized gas may be stored for several days. When inhaled, the gascan be imaged with an MRI-like scanner which produces breath by breathimages of lung ventilation, in real-time. Polarized helium-3 may thus,be used to visualize airways in static or dynamic fashion. Introducing acontrolled amount of Helium-3 through the pneumostoma and imaging thediffusion of Helium-3 into the lung over time may be utilized toevaluate the function of the pneumostoma and the prevalence ofcollateral ventilation pathways connecting the pneumostoma to theremainder of the lung. Such evaluation may be useful in determining thelocation and/or desirability of additional pneumostomas. A source ofpolarized Helium-3 may be connected to the PMD and/or pneumostoma usingone of the several techniques and mechanism described herein.

In an alternative method, a diagnostic gas is introduced through thepneumostoma and the gas is measured as it is exhaled through the naturalairways. The diagnostic gas may for example be a gas mixture such asDLCO gas used in diffusion spirometry (which nominally consists of 10%helium, 3000 ppm carbon monoxide and the balance air). The differencebetween gas concentrations in the gas introduced through the pneumostomaand exhaled by the patient is measured and factored with inspired gasvolume and other parameters to calculate factors related to collateralventilation and pneumostoma function. During exhalation, a portion ofthe breath is collected in a sample collection system and then assessedusing a helium sensor, gas chromatograph. The time course of exhalationof the diagnostic gas is indicative of factors such as pneumostomafunctionality and collateral ventilation without the need for magneticresonance imaging.

Alternative Drug Delivery Devices

FIGS. 3A and 3B show an alternative drug delivery device to delivertherapeutic agents to a pneumostoma. FIG. 3A shows a perspective view ofan alternative drug delivery device 310. FIG. 3B shows a sectional viewof the drug delivery device 310. As shown in FIGS. 3A and 3B, drugdelivery device 310 includes a therapeutic agent dispenser 312 attachedto a flange 314 which is attached to a tube 316. Flange 314 issignificantly larger than the diameter of tube 316. Flange 314 is toolarge to enter a pneumostoma and thus acts as a stop to prevent furtherinsertion of tube 316 when flange 314 makes contact with the skin of thepatient's chest. The contact surface 315 of flange 314 may also be usedto make a temporary seal surrounding the pneumostoma so that whenapplying therapeutic agent delivery to the pneumostoma there is reducedleakage of propellant/therapeutic agent around tube 316. Contact surface315 and/or tube 316 may be provided with surface features to enhance theformation of a temporary seal between flange 314 and the skin of thechest. An annular ridge 318 is shown in FIG. 3B.

Tube 316 extends far enough past flange 314 that it can pass through thethoracic wall and into the pneumostoma. Tube 316 is not however so longthat it may cause injury to the pneumostoma or lung. The length of apneumostoma varies significantly between different patients. A longertube 316 may be desirable for a longer pneumostoma. Because of thevariation in pneumostomas, drug delivery devices 310 may be manufacturedhaving tubes 316 in a range of sizes. A patient may then be providedwith a drug delivery device 310 having a tube 316 of appropriate lengthfor the patient's pneumostoma. Tubes 316 may be from 30 to 120 mm inlength and from 5 mm to 20 mm in diameter depending on the size of apneumostoma. A typical tube 240 may be between 40 mm and 80 mm in lengthand between 8 mm and 12 mm in diameter. In alternative embodiments adrug delivery device may be made with a tube 316 of a single length(such as 120 mm) which is then cut to the length appropriate for aparticular patient. Alternatively a fixed short tube may be used for allpatients—such a tube will occupy at least the entrance to thepneumostoma and therefore suffice for the delivery of the therapeuticagent. Tube 316 of drug delivery device 310 preferably has an atraumatictip 317 at the distal end to prevent injury and/or irritation to thepneumostoma during insertion.

As shown in FIGS. 3A and 3B, flange 314 and tube 316 of drug deliverydevice 310 are made in one piece and permanently attached to therapeuticagent dispenser 312. A join is shown between therapeutic agent dispenser312 and flange 314 because it is preferred that a stiffer material beused for therapeutic agent dispenser 312 and a more flexible material beused for tube 316 which enter the pneumostoma. The parts may be formedseparately and then joined by welding, gluing or otherwisebonding/connecting. Note that, for safety reasons, each of thecomponents of therapeutic agent dispenser is preferably too large to fitthrough tube 316. This prevents aspiration of any of the components intothe lung even in the event of damage to drug delivery device 310. Asshown in FIG. and 3B a pressurized canister 368 is received in sleeve370. The outlet valve 369 of canister 368 engages a fixture 372 in thebottom of sleeve 370. When the user pushes canister 368 down into sleeve370, fixture 372 activates valve 369 to release a metered dose oftherapeutic agent in a propellant gas. The therapeutic agent and gaspasses through a channel 374 in fixture 372 and are ejected into andthrough tube 316 as shown by arrow 376.

FIGS. 4A and 4B show an alternative drug delivery device 410 to supply atherapeutic agent in/through a pneumostoma. The drug delivery device 410operates in conjunction with a pneumostoma management device (PMD) 440located within a pneumostoma 110. In the PMD 440 of FIGS. 4A and 4B,tube 442 is formed in one piece with (or permanently attached to) aflange 444. PMD 440 has a hydrophobic filter 446 press fit into theproximal end of tube 442 and has a biocompatible adhesive 448 on thecontact surface 449 of flange 444 for releasably securing flange 444 tothe skin 114 of the patient's chest 100. As shown in FIG. 4D, drugdelivery device 410 has a mating section 412, having a mating surface414 designed to mate and make a temporary seal with the exterior surfaceof flange 444.

Drug delivery device 440 is utilized with PMD 440 while the tube 442 ofPMD 440 is within pneumostoma 110. As shown in FIG. 4A, to use drugdelivery device 410, hydrophobic filter 446 is first removed by pullingon tab 450. Mating surface 414 of mating section 412 is then placedagainst flange 444. In this embodiment, mating section 412 fits in thespace left by the removal of hydrophobic filter 446 as shown in FIG. 4B.When mating section 412 has formed a temporary seal with flange 444,therapeutic agent dispenser 416 is operated to dispense the therapeuticagent through the tube 442 of PMD 440 into the pneumostoma 110. Afterdispensing the therapeutic agent, the drug delivery device 410 isremoved and the hydrophobic filter 446 is press fit into the proximalend of the tube 442. Alternatively PMD 440 may be replaced with a newPMD 440.

FIGS. 5A and 5B show an alternative drug delivery device 510 to supply atherapeutic agent in/through a pneumostoma. FIG. 5A is a top down viewof drug delivery device 510 and FIG. 5B is a side view of the samedevice. The drug delivery device 510 is a dry powder drug deliverydevice. The therapeutic agent 500 in finely ground microcrystalline formis stored in a circular blister pack 512. One dose of therapeutic agent500 is located in each blister 516. In some cases the blister pack 512may be removed and replaced in other cases, drug delivery device 510 isdiscarded after all the doses in one blister pack have been used.

As shown in FIGS. 5A and 5B drug delivery device 510 includes a body 520which receives blister pack 512. Blister pack 512 is supported such thatit can rotate in body 520 and index one blister 516 at a time to adispensing position within body 520. Body 520 also carriers a manualactuator 522 on the upper surface which operates a pumping mechanism 524to force air into reservoir 526. Pumping mechanism 524 is pressurelimited so that the maximum pressure of air in reservoir 526 is cappedat a safe limit. Reservoir 526 (and/or tube 542) may also be providedwith a safety valve to release any excess pressure. Body 520 has a frontsurface 528 for making contact with the skin of the patient surroundingthe pneumostoma and limiting insertion of tube 530 to a safe depth. Thesize of tube 540 is selected so as to fit in the pneumostoma withoutcausing injury. Tube 530 has an atraumatic tip 532 at its distal end andan opening 533 through which the therapeutic agent is delivered into thepneumostoma. Two trigger buttons 534, 536 protrude from front surface528 of body 520. The trigger buttons are connected by a linkage 538 to avalve 540 of reservoir 524.

To operate drug delivery device 510 the patient depresses the manualactuator 522 one or more times. A pressure sensitive indicator (forexample venting of a relief valve) indicates when sufficient pressurehas been achieved. Tube 530 is then pushed into the pneumostoma. Whentube 530 is introduced into the pneumostoma, the trigger buttons 534 and536 contact the skin of the patient surrounding the pneumostoma. Whenslight pressure is applied to both trigger buttons 534, 536, linkage 538opens valve 540 and the air in reservoir 524 escapes via tube 542 over ablister 516 containing the therapeutic agent. One or more baffles 544 isprovided to provide turbulence to ensure that all of themicrocrystalline therapeutic agent is picked up and distributed in thestream of air and pushed through tube 530 and out of opening 533 intothe pneumostoma. In alternative embodiments, a manually operable triggermay be provided instead of trigger button 534 or 536.

Drug delivery device 510 is illustrative of an alterative therapeuticagent dispenser system which does not require a cylinder of compressedgas or propellant but instead depends on pumping action by the patient.Additionally, trigger buttons 534 and 536 fire drug delivery device 510automatically when the correct position in the pneumostoma is reached.Drug delivery device 510 has an integrated tube and insertion stop.However, in alternative embodiments, the dry powder therapeutic agentdispensing mechanism of FIGS. 5A, 5B may be incorporated in the otherdrug delivery devices discussed herein.

FIG. 6 shows an example of a drug delivery device 610 in the form of anadapter for coupling a nebulizer 600 to a chest mount 202 in order tointroduce a therapeutic agent 602 into a pneumostoma 110. Nebulizer 600is a device used to administer medication to people in the form of avapor/mist. Nebulizer 600 pumps air or oxygen through a liquidtherapeutic agent 602 (which may be liquid compound or a solution orsuspension of a therapeutic agent in a carrier liquid) to turn it into avapor/mist 604, which is then introduced to the patient via pneumostoma110. Alternatively the nebulizer produces the vapor/mist ultrasonicallyor using a vibrating micro-mesh. As shown in FIG. 6, nebulizer 600provides a vapor/mist 604 of therapeutic agent 602 under a regulated lowpositive pressure through conduit 606 to drug delivery device 610. Drugdelivery device 610 includes a tube 616 which enters pneumostoma 610. Atthe proximal end of tube 616 is a coupling 618 which engages chest mount202 to releasably secure drug delivery device 610 to chest mount 202 andwithin pneumostoma 110 while preventing over-insertion of tube 616. Inalternative embodiments drug delivery device 610 may be integrated witha flange which engages the chest of the patient surrounding thepneumostoma directly to releasably secure the drug delivery device tothe chest the patient and prevent over insertion of tube 616.

Nebulizers such as nebulizer 600 of FIG. 6 are typically plug-in devicesthat the patient may use for home treatment. In use, the patient wouldtypically remove the pneumostoma vent from the chest mount 202 andinsert the drug delivery device 610 connected to nebulizer 600.Typically a specific amount of a therapeutic agent is mixed with aspecific volume of sterile water or saline and loaded into thenebulizer. The patient would then operate the nebulizer to provide thedose of therapeutic agent for a desired period of time or until theentire dose is delivered. The patient continues to breathe normallyduring this process. As the patient breathes, the therapeutic agent willbe supplied via pneumostoma 110 into the parenchymal tissue of the lung.The therapeutic agent will then be dispersed efficiently throughout thelung by the process of collateral ventilation. Collateral ventilation isthe term given to leakage of air through the connective tissue betweenthe alveoli. Collateral ventilation may include leakage of air throughpathways that include the interalveolar pores of Kohn,bronchiole-alveolar communications of Lambert, and interbronchiolarpathways of Martin.

Drug delivery using a nebulizer may have benefits over a single pulsedelivery of drugs. Using a nebulizer allows for multiple breaths whichmay allow the therapeutic agent to effectively reach further into theparenchymal tissue allowing for better distribution and absorption.Incorporating a one-way valve or constant positive pressure through thedelivery conduit of the conduit may also be used to ensure that the drugis moving into the lung. However, it is unnecessary for the nebulizer toprovide gas at positive pressure to introduce the aerosol, mist orpowder into the lung through the pneumostoma. The nebulizer may providean aerosol, mist or powder suspended in air/gas at or near ambientpressure. Reduced pressure in the pneumostoma during inhalation by thepatient creates a sufficient pressure differential to suck the aerosol,mist or powder suspended in air/gas into the pneumostoma. A one wayvalve is configured to prevent air (and therapeutic agent) from beingexhaled out of the pneumostoma when the patient exhales. Alternatively,the nebulizer may provide a slight positive pressure using a fan, pumpor the like.

The use of nebulizer 600, as shown in FIG. 6, avoids commondisadvantages of inhaled nebulizers. When using inhaled nebulizedtherapeutic agents, the patient must wear a mask thus makingcommunication difficult. Also, the inhaled agents often taste unpleasantand may cause undesirable side effects in tissues outside the lung, suchas the mouth. Drug delivery device 610 of FIG. 6 delivers thetherapeutic agent directly to the lung tissue via pneumostoma 110thereby increasing efficiency of the delivery and reducing discomfort tothe patient. The drug delivery device 610 may also be advantageouslyutilized to deliver low pressure therapeutic gases to the patient, forexample, oxygen.

FIGS. 7A and 7B show views of an alternative drug delivery device 710according to an embodiment of the present invention. FIG. 7A shows aperspective view of an alternative drug delivery device 710. FIG. 7Bshows a sectional view of the drug delivery device 710. As shown in FIG.7A, drug delivery device 710 includes a therapeutic agent dispenser 716attached to a conical flange 714. Conical flange 714 is formed of acompliant material such that it can form a seal when pushed against aPMD. The conical shape is designed to center drug delivery device 710over a PMD to facilitate engagement of the PMD by the drug deliverydevice 710. Conical flange 714 may be provided with surface features toenhance the formation of a temporary seal between flange 714 and thePMD. A joint 718 is shown between therapeutic agent dispenser 716 andconical flange 714 because it is preferred that a stiffer material beused for therapeutic agent dispenser 716 and a more flexible material beused for conical flange 714 which mates with the PMD. The parts may beformed separately and then joined by welding, gluing or otherwisebonding/connecting. Note that, for safety reasons, each of thecomponents of drug delivery device 710 is preferably too large to fitthrough the tube 742 of a PMD. This prevents aspiration of any of thecomponents into the lung even in the event of damage to drug deliverydevice 710.

As shown in FIG. 7B, drug delivery device 710 includes a pressurizedcanister 768 is received in a sleeve 770. The outlet valve 769 ofpressurized canister 768 engages a fixture 772 in the bottom of sleeve770. When the user pushes canister 768 down into sleeve 770, fixture 772activates valve 769 to release a metered dose of therapeutic agent in apropellant gas. The therapeutic agent and gas passes through a channel774 in fixture 772 and are ejected into and through tube conical flange714 as shown by arrow 776. The alternative drug delivery mechanismspreviously discussed may also be used with a drug delivery device havinga PMD interface shown in FIG. 7B.

As shown in FIG. 7B, the drug delivery device 710 operates inconjunction with a pneumostoma management device (PMD) 740 locatedwithin a pneumostoma 110. In the PMD 740 of FIG. 7B, tube 742 is formedin one piece with (or permanently attached to) a flange 744. PMD 740 hasa hydrophobic filter 746 press fit into the proximal end of tube 742which may be removed to allow use of drug delivery device 710 (as shownin FIG. 7B). Drug delivery device 710 may however be used or modified tobe used with a PMD having a different design than shown in FIG. 7B.

As shown in FIG. 7B, conical flange 714 provides a mating sectiondesigned to mate and make a temporary seal with PMD 740. As shown inFIG. 7B, to use drug delivery device 710, hydrophobic filter 746 isfirst removed from PMD 740. Conical flange 714 is then pushed intocontact with the opening of tube 742. The tip of conical flange 714 fitsin the space left by the removal of hydrophobic filter 746. Conicalflange 714 centers drug delivery device 710 as it is pushed into tube742. Conical flange 714 also deforms slightly to make a seal against PMD740. When conical flange 714 has formed a temporary seal with PMD 740,therapeutic agent dispenser 716 is operated to dispense the therapeuticagent through the tube 742 of PMD 740 into the pneumostoma 110. Thepatient holds drug delivery device 710 against PMD 740 during dispensingthe therapeutic agent and for some seconds thereafter (preferably 3-30seconds). After dispensing the therapeutic agent, the drug deliverydevice 710 is removed and the hydrophobic filter 746 is press fit intothe proximal end of the tube 742. Alternatively PMD 740 may be replacedwith a new PMD 740.

Referring now to FIGS. 8A and 8B which show views of an alternate drugdelivery device 860 designed to be used in conjunction with PMD 801 ofFIGS. 8A and 8B as part of a pneumostoma management system. FIG. 8Ashows a perspective view of drug delivery device 860. FIG. 8B shows asectional view through drug delivery device 860 of FIG. 8A when engagedwith a chest mount 802. As shown in FIGS. 8A and 8B, drug deliverydevice 860 includes a therapeutic agent dispenser 862 and a coupling864. Drug delivery device 860 is configured such that coupling 864 maybe easily engaged with aperture 224 of a chest mount 202. Coupling 864is designed such that it is too large to pass through aperture 224 ofchest mount 202 thereby preventing insertion of drug delivery device 260into pneumostoma 110. Coupling 864 may optionally be provided with afeature such as a lip 865 for releasably engaging lip 227 of recess 228of chest mount 202.

As shown in FIGS. 8A and 8B, coupling 864 is cone-shaped being somewhatnarrower at the distal end for ease of insertion into the chest mount202. The coupling has an aperture 866 in the distal end (shown by dashedline). The conical coupling facilitates the engagement of the chestmount 202 by the drug delivery device 860. It is advantageous tosimplify this engagement in order to allow the patients to more readilycomply with their drug delivery protocols. The conical coupling alsoself centers over the pneumostoma 110. Even if the coupling 864 is offcenter when it first contacts chest mount 202, the conical shape pushescoupling 864 towards center as it enter chest mount 202.

It is also preferable for coupling 860 to make a good seal with thechest mount 202 so that leakage of propellant gas and therapeutic agentsis reduced and delivery to the pneumostoma is increased. For thisreason, the coupling 864 is preferably made of a relatively soft andcompliant material that makes a good seal with chest mount 202 whenpushed up against chest mount 202 with a modicum of force. The outersurface of coupling 864 may also be provided with structural features topromote such sealing e.g. ridge 865. In combination, the features ofcoupling 864 serve to increase delivery of the therapeutic agent to thepneumostoma.

Therapeutic agent dispenser 862 includes a mechanism for providing anaerosol, mist or powder in suspended in a propellant gas undersufficient positive pressure to enter the lung through the tube. Thetherapeutic agent dispenser preferably provides positive pressure topush the therapeutic agent into the pneumostoma. Suitable therapeuticagent dispenser mechanisms for providing metered doses of therapeuticagents in a propellant gas are known. Suitable therapeutic agentdispensers include therapeutic agent dispensing mechanisms found innebulizers, ultrasonic nebulizers, metered dose inhalers and dry powderinhalers. Dry powder therapeutic agent dispensers deliver a finemicrocrystalline suspension of therapeutic agent.

Referring again to FIGS. 8A and 8B therapeutic agent dispenser 862includes a pressurized canister 868 received in a sleeve 870. The outletvalve 869 of canister 868 engages a fixture 872 in the bottom of sleeve870. When the user pushes canister 868 down into sleeve 870, fixture 872activates valve 869 to release a metered dose of therapeutic agent in apropellant gas. The therapeutic agent and propellant gas pass through achannel 874 in fixture 870 and are ejected into through aperture 866 ofcoupling 864, through aperture 224 of chest mount 202 and intopneumostoma 110 as shown by arrow 876.

Note that in some embodiments it is unnecessary for therapeutic agentdispenser 862 to provide a propellant gas at positive pressure tointroduce the aerosol, mist or powder into the lung through thepneumostoma. In some embodiments the therapeutic agent dispenser 862provides the therapeutic agent/gas mixture at or near ambient pressure.Reduced pressure in the pneumostoma during inhalation by the patientcreates a pressure differential which sucks the therapeutic agentsuspended in air/gas into the pneumostoma.

Chest mount 202 is first positioned over a pneumostoma and secured withadhesive to the skin of the patient. In a preferred embodiment, thechest mount 202 remains attached for up to a week thereby avoidingirritation of the skin caused by daily attachment and removal of amount. Chest mount may be positioned by the patient by manual alignmentof the aperture 224 of chest mount 202 with the aperture of thepneumostoma 112. Alternatively a pneumostoma vent or an alignment toolmay be used to align the chest mount.

To use drug delivery device 860 in combination with chest mount 202 Drugdelivery device 860 is then inserted through the aperture in the chestmount until coupling 864 engages the chest mount 202. Drug deliverydevice 860 is pushed up against chest mount 202 so that coupling 864centers aperture 866 over aperture 224 of the chest mount andpneumostoma 112. Pushing drug delivery device 860 against chest mount202 also serve to make a temporary seal between coupling 864 and chestmount 202. The temporary seal reduces leakage of therapeutic agent. Drugdelivery device 860 is then operated to supply the aerosolized or drypowder therapeutic agent directly to the parenchymal tissue of the lungthrough pneumostoma 112 by operation of therapeutic agent dispenser 862.The drug delivery device 860 may be operated either by the patient,caregiver or medical practitioner.

FIG. 8C shows an example of a method of using a drug delivery deviceaccording to embodiments of the present invention. The method may bedescribed in instructions for use provided to the patient with the drugdelivery device. At step 880, the patient adjusts the pneumostomamanagement device. Depending on the operation of the drug deliverydevice, this step may involve, for example, removing a component of thepneumostoma vent such as the filter; or removing the pneumostoma vent.At step 882, the patient loads a dose of the therapeutic agent into thedrug delivery device. In some cases, the therapeutic agent is providedin single dose containers and thus this will involve loading a singledose package or indexing a package containing multiple singe dosecontainers to a full container. In other cases, the therapeutic agentwill be in a multiple-use container, such as a pressurized metered dosecanister and it will be unnecessary for the patient to load atherapeutic agent dose unless the container is empty. The drug deliverydevice is now prepared for operation.

At step 884, the patient positions the distal end of the coupling in theaperture of the chest mount or pneumostoma vent and pushes the drugdelivery device against the chest mount or pneumostoma vent (whichserves to accurately position aperture 866 of the drug delivery deviceand make a temporary seal between coupling 864 and chest mount 202). Asthe distal end of the coupling enters the aperture it centers thecoupling. As the distal tip is pushed against the aperture, thecompliant surface makes a temporary seal against the pneumostoma ventand/or chest mount. After the coupling has centered and self-sealed, thetherapeutic agent may be administered.

In a typical therapeutic agent delivery operation the patient will firstexhale through the nose/mouth at step 885 immediately prior to actuatingthe drug delivery device. At step 886 the drug delivery device isactuated to mix the therapeutic agents (aerosol, gas or dry powder) inthe propellant/air. In some embodiments this mixing step requires arelatively high air speed/pressure. It may be undesirable for thisairspeed/pressure to be applied to the pneumostoma and thus the locationof mixing step 886 may be separated by features to reduce theairspeed/pressure distance before the mixture reaches the pneumostoma.Such features may include, for example, space, volume, baffles and thelike. At step 888 application of positive pressure is used to propel themixture of therapeutic agent and propellant into the pneumostoma and/orthrough the pneumostoma into the lung. The positive pressure applied atthis step may be substantially less than the pressure used at step 886.The positive pressure may be supplied by a different mechanism or by amodulation of the same mechanism. Steps 886 and 888 may be combined inone step for example where the pressure is modulated by the mechanics ofthe device such that a higher local pressure is available in one part ofthe device to mix the agent but is reduced by the time it reaches thepneumostoma. Note that in some embodiments it is unnecessary for thetherapeutic agent dispenser to provide propellant gas at positivepressure to introduce the aerosol, mist or powder into the lung throughthe pneumostoma. In some embodiments the drug delivery device remains ator near ambient pressure and reduced pressure in the pneumostoma duringinhalation by the patient creates a pressure differential which sucksthe aerosol, mist or powder suspended in air/gas into the pneumostoma.

At step 890, air is introduced through the pneumostoma to aiddistribution of the therapeutic agent through the lung tissue bycollateral ventilation. Step 890 is optional and may in some cases becombined with step 888. In some cases step 890 may be achieved by thepatient “inhaling” through the pneumostoma in which the patient expandsthe ribcage thereby creating a negative pressure in the chest to drawair in through the pneumostoma. In some circumstances this “inhalation”through the pneumostoma may be enhanced by obstructing the nose andmouth while expanding the ribcage. However, step 890 may not benecessary and a therapeutic agent may be efficiently distributed fromthe pneumostoma through parenchymal tissue of the lung by collateralventilation without the need for additional intake of air through thepneumostoma.

At step 892, the patient optionally holds their breath for a time priorto exhaling, such as 10 to 15 seconds. This step may not be necessaryfor therapeutic agents delivered into the pneumostoma. Because thetherapeutic agent was not delivered through the natural airways, it willnot be rapidly exhaled through the natural airways. Indeed, in somecases breathing normally (while obstructing the pneumostoma) while causerapid distribution of the therapeutic agent through the lung with littleloss of therapeutic agent due to exhalation. In some case it may beadvantageous to provide a slight positive pressure of air to thepneumostoma after delivery of the therapeutic agent to promote diffusionof the therapeutic agent through the lung. Steps 884 and 892 may berepeated a number of times if necessary to deliver multiple doses oftherapeutic agent as shown by dashed arrow 894.

It may be desirable to leave the drug delivery device in place for aperiod after delivery of therapeutic agent to prevent the agent frombeing ejected through the pneumostoma. After the therapeutic agent hasbeen delivered, the drug delivery device is pulled away from the chestmount and/or pneumostoma vent at step 896. At step 898, any removedcomponents of the pneumostoma management device are reattached. Any orall of the above steps may be performed and/or controlled by a physicianor caregiver instead of the patient. The therapeutic agent deliverysteps may be repeated according to a particular dosing schedule or asneeded depending on the therapeutic agent and/or physician'sinstructions.

FIGS. 9A and 9B show an alternative drug delivery device 910 to supply atherapeutic agent in/through a pneumostoma. The drug delivery device 910operates in conjunction with a pneumostoma management device (PMD) 940located within a pneumostoma 110. In the PMD 940 of FIGS. 9A and 9B,tube 942 is formed in one piece with (or permanently attached to) aflange 944. PMD 940 has a hydrophobic filter 946 press fit into theproximal end of tube 942 and has a biocompatible adhesive 948 on thecontact surface 949 of flange 944 for releasably securing flange 944 tothe skin 114 of the patient's chest 100. As shown in FIG. 9D, drugdelivery device 910 has a mating section 912, having a mating surface914 designed to mate and make a temporary seal with the exterior surfaceof flange 944. Mating section 912 also has a distal tip 916 designed toaid in the coupling of mating section 912 with PMD 940.

Drug delivery device 940 is utilized with PMD 940 while the tube 942 ofPMD 940 is within pneumostoma 110. As shown in FIG. 9A, to use drugdelivery device 910, hydrophobic filter 946 is first removed by pullingon tab 950. Distal tip 916 of mating section 912 is placed against PMD940. Distal tip 916 guides mating section 912 into the aperture of PMD940. As drug delivery device 910 is pushed towards PMD 940, distal tip916 centers mating section 912 over the aperture in the PMD 940 aligningaperture 918 with the PMD 940. Mating surface 914 of mating section 912contacts flange 944. Mating section 914 is made of a compliant materialand thus forms a temporary seal between the drug deliver device 910 andthe PMD 940. In this embodiment, mating section 912 fits in the spaceleft by the removal of hydrophobic filter 946 as shown in FIG. 9B. Whenmating section 912 has formed a temporary seal with flange 944,therapeutic agent dispenser 916 is operated to dispense the therapeuticagent through the tube 942 of PMD 940 into the pneumostoma 110. Afterdispensing the therapeutic agent, the drug delivery device 910 isremoved and the hydrophobic filter 946 is press fit into the proximalend of the tube 942. Alternatively PMD 940 may be replaced with a newPMD 940.

Pneumostoma Assessment Using Gas

Measurement of gases entering or leaving the pneumostoma may be usefulfor assessing the functionality of the pneumostoma. The ability of gasto pass through the pneumostoma may be measured in a number of ways.First, gas flow through the pneumostoma can be measured passively byplacing a device over the pneumostoma which measures airflow out ofand/or into the pneumostoma during regular breathing of the patient.Essentially, gases exiting the pneumostoma are collected by a systemwhich records the volume of gas. Additionally, the gas may be analyzedto determine composition of the gases exiting the pneumostoma.

As shown in FIG. 10A, a gas analysis device 1000 is inserted into thepneumostoma 110 of a patient. Gas analysis device 1000 is connected bytube 1002 to gas analyzer 1012. The gases exhaled from the pneumostoma110 may then be examined during normal breathing or during an exercisetest. The exhaled gas may be examined to determine oxygen and carbondioxide concentrations. In some cases, the concentrations are comparedto oxygen and carbon dioxide concentrations in the gases exhaled throughthe natural airways. Such evaluation may be useful in determining theeffectiveness of a pneumostoma and the location and/or desirability ofadditional pneumostomas. The output of gas analyzer 1012 may be providedto a computer system 1014 to display the results of the gas analysis.Optionally, a mask 1016 may be provided. Mask 1016 may be used tomeasure the volume of gas inhaled and exhaled by the patient through thenatural airways. The volume of gas inhaled and exhaled through thenatural airways may be compared to the volume of gas exiting thepneumostoma.

In another example, a diagnostic gas is introduced through the naturalairways and the expiration of gases from the pneumostoma is measured. Asshown in FIG. 10A, optional mask 1016 may be used to provide adiagnostic gas mixture 1018 via the natural airways. The concentrationof gases exiting the pneumostoma 110 may be compared to theconcentration of gases in the diagnostic gas supply 1018. Thetime-course of exhalation of diagnostic gases through the pneumostomamay be analyzed by gas analyzer 1012 to evaluate the function of thepneumostoma and the prevalence of collateral ventilation pathwaysconnecting the pneumostoma to the remainder of the lung. Such evaluationmay be useful in determining the effectiveness of a pneumostoma and thelocation and/or desirability of additional pneumostomas. Gas analysisequipment may be connected to a PMD and/or pneumostoma using one of theseveral techniques and mechanisms described herein.

Alternatively, gas may be provided through the pneumostoma from outsidethe chest of the patient. The gas is preferably supplied at a controlledpressure slightly above the ambient air pressure so as not to causeinjury to the pneumostoma. In a simple case, the rate of flow of gasinto the lung through the pneumostoma may be measured. The rate of gasflow may be used to assess the patency of the pneumostoma.Alternatively, diagnostic gases may be introduced through thepneumostoma for assessing collateral ventilation and gas exchange.Diagnostic gases may be helpful in measuring functional attributes ofthe pneumostoma and the lung. In particular, introduction of diagnosticgases through the pneumostoma may be useful for assessing gas diffusionbetween the pneumostoma and the lung.

In one example, a diagnostic gas is introduced through the pneumostomaand the gas is measured as it is exhaled through the natural airways.The diagnostic gas may, for example, be a gas mixture such as DLCO gasused in diffusion spirometry (which nominally consists of 10% helium,3000 ppm carbon monoxide and the balance air). Gases exhaled through thenatural airways are analyzed to determine gas concentrations. The timecourse of exhalation of the diagnostic gas is indicative of factors suchas pneumostoma functionality and collateral ventilation. Where thediagnostic gas is introduced via the pneumostoma the time course ofexhalation of gas through the natural airways may be analyzed toevaluate the function of the pneumostoma and the prevalence ofcollateral ventilation pathways connecting the pneumostoma to theremainder of the lung. Such evaluation may be useful in determining theeffectiveness of a pneumostoma and the location and/or desirability ofadditional pneumostomas. A supply of the diagnostic gas may be connectedto a PMD and/or pneumostoma using one of the several techniques andmechanisms described herein.

FIG. 10B shows a schematic view of a lung assessment system usingintroduction of diagnostic gas 1018 through a pneumostoma 110. As shownin FIG. 10B a gas analysis device 1000 is inserted into the pneumostoma110 of a patient. Gas analysis device 1000 is connected by tube 1002 toa pressure regulated source of diagnostic gas 1018. Asolenoid-controlled valve 1006 in tube 1002 controls the flow ofdiagnostic gas into pneumostoma 110. The patient is provided with a mask1016 which allows the patient to inhale ambient air but that collectsthe exhaled air and passes it to gas analyzer 1012. During exhalation, aportion of the exhaled gases is collected in a sample collection systemand then analyzed using discrete gas sensors and/or a gas chromatograph.The gas analyzer 1012 and the solenoid-controlled valve 1006 areconnected to a control system 1020 which may be a general purposecomputer. Control system 1020 controls solenoid-controlled valve 1006and receives data from gas analyzer 1012. Control system 1020 analyzesthe gas concentrations in the gas exhaled by the patient and factors therelative values with inspired gas volume and other parameters tocalculate factors related to collateral ventilation and pneumostomafunction.

Introduction of diagnostic gases through a pneumostoma may also be usedto enhance imaging the lung with a CT scan or NMR scan. For examplepolarized Helium-3 may be utilized to enhance nuclear magneticresonance/magnetic resonance imaging of the lung (analogous to the waycontrast agents enhance X-ray imaging). For example, polarized helium-3may be produced with lasers and the magnetized pressurized gas may bestored for several days. When introduced into the lung, the polarizedhelium-3 can be imaged with an MRI-like scanner which producesbreath-by-breath images of lung ventilation, in real-time. Polarizedhelium-3 may thus, be used to visualize airways in static or dynamicfashion. Alternative gases which may be used as visualization agentsinclude gaseous radionuclide xenon or technetium DTPA in an aerosolform.

Introducing a controlled amount of a visualizable gas, e.g. polarizedHelium-3, through the pneumostoma and imaging the diffusion of the gasinto the lung over time may be utilized for quantitative evaluation ofthe function of the pneumostoma and the prevalence of collateralventilation pathways connecting the pneumostoma to the parenchymaltissue of the lung. Measuring the time-course variations in diffusion ofHelium-3 into the lung allows analysis of diffusion coefficients forareas of the lung. Such evaluation may be useful in determining theeffectiveness of a pneumostoma and the location and/or desirability ofadditional pneumostomas. A source of polarized Helium-3 may be connectedto a PMD and/or pneumostoma using one of the several techniques andmechanisms described herein.

FIG. 10C shows a schematic view of a lung assessment system using adiagnostic gas in conjunction with an imaging scanner 1050. Scanner 1050may be an MRI, NMR, CT or X-Ray so long as the particular diagnostic gasused may be successfully imaged with the system. As shown in FIG. 10B,gas analysis device 1000 is inserted into the pneumostoma 110 of apatient. Gas analysis device 1000 is connected by tube 1030 to apressure-regulated source of a visualizable gas (e.g. polarizedHelium-3). A solenoid-controlled valve 1032 in tube 1030 controls theflow of diagnostic gas into pneumostoma 110. The scanner 1050 and thesolenoid-controlled valve 1032 are connected to a control system 1020(not shown) which may be a general purpose computer. The control system1020 (not shown) controls solenoid-controlled valve 1032 and receivesdata from scanner 1050. The control system 1020 coordinates theintroduction of diagnostic gas into the patient with the patient'sbreathing and also with the operations of scanner 1050 in order toaccurately image dispersion of the diagnostic gas from the pneumostoma110 to other parts of the lung. Control system 1020 analyzes the timecourse distribution of the diagnostic gas from the pneumostoma into thelung tissues to calculate factors related to collateral ventilation andpneumostoma function, e.g. diffusion coefficients.

FIGS. 10D and 10E show views of the gas analysis device 1000 of FIGS.10A-10C. FIG. 10D shows a perspective view of the gas analysis device1000 while FIG. 10E shows a sectional view of gas analysis device 1000positioned within a pneumostoma. In general terms, gas analysis device1000 is a device which can be secured into a pneumostoma for samplinggases exiting the pneumostoma and/or providing gases into thepneumostoma. Gas analysis device 1000 can form part of a system whichutilizes such gas sampling or gas provision for assessment ofpneumostoma function and/or lung function. As used in FIGS. 10A and 10C,gas analysis device 1000 is used to introduce diagnostic gas into thepneumostoma. As used in FIG. 10B, gas analysis device 1000 is used tocollect gases exhaled from the lung for analysis by gas analyzer 1012.

Referring to FIG. 10D, gas analysis device 1000 includes a hollow tube1060 for insertion into the pneumostoma. Hollow tube 1060 is surroundedby a flange 1062 which secures tube 1060 in position in the pneumostoma.Hollow tube 1060 connects to a coupling 1064 on the proximal side offlange 1062. Coupling 1064 is configured so that tube 1002 may bereadily connected and disconnected. Hollow tube 1060 has one or moreholes 1066 at the distal end through which gas may pass into or out ofthe pneumostoma. Hollow tube 1060 and flange 1062 also provide atemporary seal which inhibits leakage of gas from around hollow tube1060.

FIG. 10E shows a sectional view of gas analysis device 1000 of FIGS.10A-4D in position in a pneumostoma 110. It is preferable to minimizeleakage of gases into or out of the pneumostoma. Flange 1062 is thusprovided with an adhesive coating 1068 on the distal surface to providea temporary seal between the gas analysis device 1000 and the skin ofthe chest of the patient. Surface features may also be provided on thedistal surface of flange 1062 or on tube 1060 to promote sealing betweengas analysis device 1000 and the pneumostoma. For example, a circularridge 1070 is shown in section on FIG. 10E. Gas analysis device 1000 ispreferably a disposable component that will be used only with onepatient. One or more filters may be interposed between gas analysisdevice 1000 and the gas supply and/or gas analyzer to prevent possiblecross-contamination between patients.

Delivery of Therapeutic Agents By the PMD/Vent

The tube of a PMD such as pneumostoma vent system 1100 may be designedto deliver a pharmaceutically-active substance. A“pharmaceutically-active substance” is an active ingredient ofvegetable, animal or synthetic origin which is used in a suitable dosageas a therapeutic agent for influencing conditions or functions of thebody, as a replacement for active ingredients naturally produced by thehuman or animal body and to eliminate or neutralize disease pathogens orexogenous substances. The release of the substance in the environment ofpneumostoma vent has an effect on the course of healing and/orcounteracts pathological changes in the tissue due to the presence ofpneumostoma vent. In particular, it is desirable in some embodiments tocoat or impregnate pneumostoma vent with pharmaceutically-activesubstances that preserve the patency of pneumostoma and/or areantimicrobial in nature but that do not unduly irritate the tissues ofthe pneumostoma. In particular cases, suitable pharmaceutically-activesubstances may have an anti-inflammatory and/or antiproliferative and/orspasmolytic and/or endothelium-forming effect, so that the functionalityof the pneumostoma is maintained. However the pneumostoma vent may alsodeliver, be coated with or be impregnated with time-release therapeuticagents design to have effects on tissues other than the tissues of thepneumostoma. Suitable pharmaceutically-active substances include thosedescribed above.

FIGS. 11A-11C shows different views of a pneumostoma vent system 1100 (apneumostoma management device). Pneumostoma vent system 1100 is designedfor use without a chest mount although it could be adapted for use witha chest mount. FIG. 11A shows an exploded view of the four maincomponents of pneumostoma vent system. From right to left thesecomponents are annular adhesive cover 1102, filter 1104, pneumostomavent 1106 and hydrocolloid ring 1108.

Annular adhesive cover 1102 is a thin porous biocompatible membranewhich is adhesive on the surface facing the pneumostoma (the innersurface see 1122 in FIG. 11C) and non-adhesive on the outer surface1120. A suitable material for annular adhesive cover 1102 is a CHGChlorhexidine Gluconate IV Securement Dressing available under theTradename TEGADERM™ from 3M of St. Paul, Minn. TEGADERM™ is thin layerof polyurethane bonded to a thin hydrocolloid adhesive layer. The filmis biocompatible as well as thin, strong, and breathable. Other thinbiocompatible dressings and adhesive films may be used as an alternativeto TEGADERM™. Annular cover 1102 has an aperture 1124 large enough toallow air to exit through filter 1104. Aperture 1124 may however beslightly smaller than filter 1104 so that annular cover can be used tosecure filter 1104 to pneumostoma vent 1106. Exposed portions of annularadhesive cover 1102 are provided with a paper cover to protect theadhesive ring prior to use.

Filter 1104 is a circular disc of filter material. Filter 1104 ispreferably a hydrophobic filter material, for example GORETEX. Filter1104 is larger than the proximal aperture in pneumostoma vent 1106 andis positioned over the proximal aperture to filter material moving inand out of the pneumostoma vent 1106. Filter 1104 may be secured topneumostoma vent 1106 by and adhesive, welding, or other bondingtechnology. Filter 1104 may also be secured to pneumostoma vent 1106 byannular adhesive cover 1102 instead of or in addition to other bondingtechniques.

Pneumostoma vent 1106 comprises a tube 1130 for entering thepneumostoma. As previously discussed, tube 1130 has an atraumatic tip1165 and one or more apertures 1167 in the distal end to allows gasesand discharge to enter tube 1130 from the pneumostoma. Tube 1130 isconnected to a flange 1132 at the proximal end. Flange 1132 may beformed in one piece with tube 1130 or formed separately and joined totube 1132 as previously described with respect to other embodiments. Theproximal opening 1163 of pneumostoma vent is sized so that filter 1104covers proximal opening 1163. Filter 1104 is secured over proximalopening 1163 as described in the previous paragraph.

Hydrocolloid ring 1108 is a biocompatible hydrocolloid material which isadhesive on both sides. Hydrocolloid ring may be provided with a filmcoating and a transitional adhesive on the side facing flange 1132 andannular cover 1102 in order to better secure hydrocolloid ring 1108 tothe flange and annular cover. Hydrocolloid ring 1108 is preferably lessthan 3 mm thick and is more preferably, approximately 1 mm in thickness.Exposed portions of hydrocolloid ring 1108 are provided with a papercover to protect the adhesive ring prior to use.

Pneumostoma vent system 1100 may be provided as a kit of separatecomponents or one or more of the components may be preassembled whenprovided to the patient. FIG. 11B shows an assembly of all four maincomponents including annular adhesive cover 1102, filter 1104,pneumostoma vent 1106 and hydrocolloid ring 1108. Note that tube 1130fits through the middle of hydrocolloid ring 1108. Note also that flange1132 is trapped between annular adhesive cover 1102 and hydrocolloidring 1108. In this embodiment, filter 1104 is also secured topneumostoma vent 1106 by annular adhesive cover 1102. Exposed adhesiveregions of annular adhesive ring 1102 and hydrocolloid ring 1108 on thepatient side of the pneumostoma vent system assembly are provided withprotective covers (for example paper covers) to protect the adhesiveduring shipping and prior to use. The completed or partially completedassembly is provided as a sterile product to the patient or caregiverwho inserts the pneumostoma vent into a pneumostoma as part of apneumostoma care program.

FIG. 11C shows a sectional view of the pneumostoma vent system 1100 inposition within a pneumostoma 110. As shown in FIG. 11C, tube 1130 isinserted into the pneumostoma and passes through the chest wall into thelung. Aperture 1167 in the distal end of tube 1130 is positioned insidethe lung so that gases and discharge may enter the tube 1130 of thepneumostoma vent system. Flange 1132 of pneumostoma vent 1106 is securedto the skin of the patient by hydrocolloid ring 1108 and annularadhesive cover 1102. Flange 1132 secures the position of tube 1130within pneumostoma 110. Flange 1132 secures the position of aperture1163 on the chest of the patient such that gases from the lung may ventthrough tube 1130 and filter 1104. Both hydrocolloid ring 1108 andannular adhesive cover 1102 contact the skin 114 of the patient tosecure the pneumostoma vent system. In some cases a barrier film may beapplied by the patient prior to securing the pneumostoma vent system toreduce skin irritation caused by application and removal of the system.An additional ring of absorbent material (not shown), for example, gauzeor another absorbent fabric may be positioned around tube 1130 betweenhydrocolloid ring 1108 and the skin 114 of the patient for absorbing anydischarge from pneumostoma 110 which escapes around tube 1130.

The components of the pneumostoma management system are preferablysupplied to the patient in sterile packaging. In preferred embodiments,the components are supplied in packaging that assists the patient inutilizing the components of the system in the correct sequence. Thepackaging should include instructions for use. The packaging may also beprinted with material that assists the patient in the appropriatesequence of the steps for using the enclosed components. The package mayalso be designed to provide the components to the patient in the orderrequired for use and maintain sterility during use. For example, thepackage may be designed so that, upon opening the package, thecomponents are physically laid out in a tray in the order in which theyare to be used by the patient. Alternatively, the components may beprovided as individual components separately packaged. For example,cleaning and moisturizing swabs and barrier spray/cream mayalternatively or additionally be packaged separately and provided topatient.

Referring again to FIG. 11C which shows a sectional view of thepneumostoma vent system 1100 in position within a pneumostoma 110. Asshown in FIG. 11C, tube 1130 is inserted into the pneumostoma and passesthrough the chest wall into the lung. Tube 1130 may be coated with apharmaceutically-active substance along all or part of tube 1130.

As shown in FIG. 11C tube 1130 is provided with apharmaceutically-active coating 1140 including a pharmaceutically-activesubstance. Coating 1140 is limited to the distal tip of tube 1140.However coating may also be provided over the entirety of tube 1130 ordifferent coatings provided in different regions of tube 1140 dependingupon the intended function of the coating. Coating 1140 is in contactwith thin vascularized epithelium of the pneumostoma at the perimeter ofpneumostoma 110. Thus depending on the pharmaceutical, thepharmaceutically-active substance may diffuse from coating 1140 into thecells of the pneumostoma, and from those cells into the bloodstream ofthe patient. The coating 1140 preferably releases thepharmaceutically-active substance over the time of use (such as a day)to main dosage consistency. The pharmaceutically-active substance may beselected to treat the tissues of the pneumostoma for example to maintainpatency, reduce tissue growth, or inhibit infection. Thepharmaceutically active substance may alternatively be selected to treatthe patient systemically for example by providing a hormone to beabsorbed into the blood stream via the tissues of the pneumostoma.

As shown in FIG. 11C the material of tube 1130 of pneumostoma ventsystem 1100 may also be impregnated with a pharmaceutically-activesubstance 1142. Depending upon the material, the pharmaceutically-activesubstance may be added before or after forming the material into thedesired shape. The pharmaceutically-active substance is eluted from thetube 1130 over time while the tube 1130 is in contact with thepneumostoma. The tube 1130 preferably releases thepharmaceutically-active substance gradually over the time of use (suchas a day) to main dosage consistency. The pharmaceutically-activesubstance may be selected to treat the tissues of the pneumostoma forexample to maintain patency, reduce tissue growth, or inhibit infection.The pharmaceutically-active substance may alternatively be selected totreat the patient systemically for example by providing a hormone toabsorbed into the blood stream via the tissues of the pneumostoma.

FIG. 11D shows an alternate embodiment of a pneumostoma vent system 1150with drug delivery features. As before, pneumostoma vent system includesfilter 1104, annular adhesive cover 1102, hydrocolloid ring 1108.However vent 1156 comprises a tube 1160 for entering the pneumostomawhich has an additional lumen 1162 for delivery of a pharmaceuticallyactive substance fluid in addition to the lumen 1161 through gases mayescape from the pneumostoma. Lumen 1161 passes along the length of tube1130 and exits tube 1130 at one or more apertures 1164. One or moreapertures 1164 are preferably located in the distal half of tube 1160 soas to releases the pharmaceutically active fluid into contact withhighly vascularized tissue in the lung to facilitate absorption. Vent1156 has a flange 1158 at the proximal end. Lumen 1162 is accessiblethrough flange 1158 by means of access port 1166. Access port 1166 marksthe location of lumen 1162. Access port 1166 is preferably closed untilmated with a device for supplying the pharmaceutically active fluid intolumen 1162.

FIG. 11E shows an enlarged view of an embodiment of an access port 1166.As shown in FIG. 11E access port 1166 is marked by an opening 1170 inadhesive cover 1102 which exposes flange 1158. The distal end of lumen1162 is obstructed by a diaphragm 1172. Diaphragm 1172 may be formedfrom cover 1102, the material of flange 1158 or an additional thin pieceof material. To access lumen 1162 the sharp tip of a tube (not shown)pierces the diaphragm allowing a fluid to be injected through the tubeinto the lumen 1162. For example a syringe may be used with a shortneedle to inject a pharmaceutically-active fluid through diaphragm intolumen 1162. The fluid passes along lumen 1162 and out of aperture 1162(FIG. 11D) into the pneumostoma where it may be absorbed. This is asuitable technique for periodic or intermittent supply of apharmaceutically-active fluid to the patient. Where a continuous,regular and/or automatic supply of pharmaceutically-active fluid isdesired, a supply line 1180 may be coupled to lumen 1162 as shown inFIG. 11E. Supply line 1180 is connected by a coupling 1182 to accessport 1166. Coupling 1182 may include an adhesive flange 1184 and a shortneedle 1186. Short hollow needle 1186 penetrates diaphragm 1172 toconnect supply line 1180 to lumen 1162. Access port 1166 and coupling1182 may include other suitable medical connectors for connecting onetube to another, for example, Luer or Tuohy Borst fittings. The otherend (proximal end) of supply line 1180 is connected to a drug pump 1190.Drug pump 1190 (shown schematically) is preferably a self-containedambulatory unit having a power supply 1192, pump 1194, pump controller1196 and a reservoir 1198 containing a supply of thepharmaceutically-active fluid 1199. Drug pump 1190 may be, for example abelt mounted unit approximately the size of a cell phone. Pump 1194pumps a metered supply of the pharmaceutically-active fluid 1199 fromthe reservoir 1198 into the supply line 1180 under the control ofcontroller 1196 and powered by power supply 1192. Suitable portable drugpumps are known in the art and described, for example, in U.S. Pat. No.7,347,836 to Peterson et al. and references cited therein.

In use, controller 1196 meters the amount of pharmaceutically-activefluid 1199 supplied to the patient according to preset programming, userinput or sensors. For example, where the pharmaceutically-active fluidis insulin or an insulin analog, controller 1196 may cause pump 1194 tosupply insulin to supply line 1180 in response to elevated glucoselevels detected by a glucose sensor. From supply line 1180 thepharmaceutically-active fluid 1199 passes through coupling 1182 andaccess port 1166 via lumen 1162 into the pneumostoma where it isabsorbed into the bloodstream of the patient. The present invention hasthe advantage of providing a means for continuous administration andrapid absorption of the pharmaceutically-active fluid 1199 withoutrequiring injection through the skin or oral administration.

Materials

In preferred embodiments, the PMD and drug delivery device are formedfrom biocompatible polymers or biocompatible metals. A patient willtypically wear PMD at all times and thus the materials, particularly oftubes entering the pneumostoma, should meet high standards forbiocompatibility. In general preferred materials for manufacturing thePMD and drug delivery device are biocompatible thermoplastic elastomersthat are readily utilized in injection molding and extrusion processing.As will be appreciated, other suitable similarly biocompatiblethermoplastic or thermoplastic polymer materials can be used withoutdeparting from the scope of the invention. Biocompatible polymers formanufacturing PMD and drug delivery device may be selected from thegroup consisting of polyethylenes (HDPE), polyvinyl chloride,polyacrylates (polyethyl acrylate and polymethyl acrylate, polymethylmethacrylate, polymethyl-coethyl acrylate, ethylene/ethyl acrylate),polycarbonate urethane (BIONATEG), polysiloxanes (silicones),polytetrafluoroethylene (PTFE, GORE-TEX®,ethylene/chlorotrifluoroethylene copolymer, aliphatic polyesters,ethylene/tetrafluoroethylene copolymer), polyketones(polyaryletheretherketone, polyetheretherketone,polyetheretherketoneketone, polyetherketoneetherketoneketonepolyetherketone), polyether block amides (PEBAX, PEBA), polyamides(polyamideimide, PA-11, PA-12, PA-46, PA-66), polyetherimide, polyethersulfone, poly(iso)butylene, polyvinyl chloride, polyvinyl fluoride,polyvinyl alcohol, polyurethane, polybutylene terephthalate,polyphosphazenes, nylon, polypropylene, polybutester, nylon andpolyester, polymer foams (from carbonates, styrene, for example) as wellas the copolymers and blends of the classes listed and/or the class ofthermoplastics and elastomers in general. Reference to appropriatepolymers that can be used for manufacturing PMD and drug delivery devicecan be found in the following documents: PCT Publication WO 02/02158,entitled “Bio-Compatible Polymeric Materials;” PCT Publication WO02/00275, entitled “Bio-Compatible Polymeric Materials;” and, PCTPublication WO 02/00270, entitled “Bio-Compatible Polymeric Materials”all of which are incorporated herein by reference. Other suitablematerials for the manufacture of the PMD include medical grade inorganicmaterials such stainless steel, titanium, ceramics and coated materials.Hydrophobic filter materials should be sufficiently porous to allow airto exit through the filter. Materials for hydrophobic filters areavailable commercially and filters can be fabricated from any suitablehydrophobic polymer, such as tetrafluoroethylene, PTFE, polyolefins,microglass, polyethylene and polypropylene or a mixture thereof. Inpreferred examples, the hydrophobic filter is a laminatedtetrafluoroethylene e.g. TEFLON®, (E.I. du Pont de Nemours Co.) orGORE-TEX® (W.L. Gore, Inc.) of a controlled pore size. In other examplesthe hydrophobic filter may comprise a felted polypropylene;PTFE/polypropylene filter media.

The foregoing description of preferred embodiments of the presentinvention has been provided for the purposes of illustration anddescription. It is not intended to be exhaustive or to limit theinvention to the precise forms disclosed. Many embodiments were chosenand described in order to best explain the principles of the inventionand its practical application, thereby enabling others skilled in theart to understand the invention for various embodiments and with variousmodifications that are suited to the particular use contemplated.Embodiments of the present invention may use some or all of the featuresshown in the various disclosed embodiments where such features are notstructurally or functionally incompatible. It is intended that the scopeof the invention be defined by the claims and their equivalents.

1. A therapeutic agent delivery device adapted to deliver a therapeuticagent through a pneumostoma management device wherein the therapeuticagent delivery device comprises: a container adapted to receive at leastone dose of the therapeutic agent; a self-sealing dispensing port thatis adapted to communicate with the pneumostoma management device; and anactuator that can release the therapeutic agent through the dispensingport and into the pneumostoma management device.
 2. The device of claim1, wherein the dispensing port is adapted to be self centering on anaperture of the pneumostoma management device.
 3. The device of claim 1,wherein the dispensing port includes a conical flange adapted to engagean aperture of the pneumostoma management device.
 4. The device of claim1, wherein the dispensing port includes a self-sealing flange adapted toseal against a perimeter of an aperture of the pneumostoma managementdevice.
 5. The device of claim 1, wherein the dispensing port includes acompliant flange adapted to seal against a perimeter of an aperture ofthe pneumostoma management device.
 6. The device of claim 1, wherein thedispensing port includes a deformable flange adapted to seal against aperimeter of an aperture of the pneumostoma management device.
 7. Thedevice of claim 1 wherein said container is adapted to receive arepository of one or more doses of the therapeutic agent.
 8. The deviceof claim 1 wherein said container is adapted to receive the output of anebulizer.
 9. The device of claim 1 wherein said container is adapted toreceive a canister of the therapeutic agent.
 10. The device of claim 1wherein said container is adapted to receive a repository havingindividually defined doses of the therapeutic agent.
 11. The device ofclaim 1 including a repository having one or more doses of thetherapeutic agent, which repository is selectably receivable by thecontainer.
 12. The device of claim 1 including a canister of thetherapeutic agent, which canister is selectably receivable by thecontainer.
 13. A therapeutic agent delivery device adapted to deliver atherapeutic agent through a pneumostoma management device wherein thetherapeutic agent delivery device comprises: a container adapted toreceive at least one dose of the therapeutic agent; a self-centering andself-sealing dispensing port that is adapted to communicate with thepneumostoma management device; and an actuator that can release thetherapeutic agent through the dispensing port and through thepneumostoma
 14. The device of claim 13 wherein said dispensing port isconical.
 15. The device of claim 13 wherein said dispensing port iscompliant.
 16. The device of claim 13 wherein said dispensing port isdeformable.
 17. The device of claim 13, wherein the dispensing portincludes a conical flange adapted to engage an aperture of thepneumostoma management device.
 18. The device of claim 13, wherein thedispensing port includes a self-sealing flange adapted to seal against aperimeter of an aperture of the pneumostoma management device.
 19. Thedevice of claim 13, wherein the dispensing port includes a compliantflange adapted to seal against a perimeter of an aperture of thepneumostoma management device.